Provider Demographics
NPI:1467836478
Name:BROUSSARD, KALLYN JONES (NP)
Entity Type:Individual
Prefix:MS
First Name:KALLYN JONES
Middle Name:
Last Name:BROUSSARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 4TH ST STE 5B
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71301-8421
Mailing Address - Country:US
Mailing Address - Phone:318-767-0605
Mailing Address - Fax:318-767-0086
Practice Address - Street 1:211 4TH ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-8421
Practice Address - Country:US
Practice Address - Phone:337-208-2361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-20
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP08444363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care