Provider Demographics
NPI:1497743645
Name:KELONE, SUSAN TRACY FRYAR (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:TRACY FRYAR
Last Name:KELONE
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 1:248 GRAYS CREEK RD
Mailing Address - Street 2:
Mailing Address - City:DRY PRONG
Mailing Address - State:LA
Mailing Address - Zip Code:71423-3539
Mailing Address - Country:US
Mailing Address - Phone:318-442-2339
Mailing Address - Fax:318-442-2340
Practice Address - Street 1:3425 NORTH BLVD
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3676
Practice Address - Country:US
Practice Address - Phone:318-442-2339
Practice Address - Fax:318-442-2340
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAPO4542363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1620467Medicaid
LAP00203569OtherRAILROAD MEDICARE
LAQ35294Medicare UPIN
LA1620467Medicaid