Provider Demographics
NPI:1578966768
Name:CALLOWAY, KELLY (APRN)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:
Last Name:CALLOWAY
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:BURCKEL
Other - Last Name:CALLOWAY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4150 NELSON RD
Mailing Address - Street 2:BUILDING E SUITE 1
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-4148
Mailing Address - Country:US
Mailing Address - Phone:337-474-1386
Mailing Address - Fax:
Practice Address - Street 1:4150 NELSON RD
Practice Address - Street 2:BUILDING E SUITE 1
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-4148
Practice Address - Country:US
Practice Address - Phone:337-474-1386
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-01
Last Update Date:2016-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2381393Medicaid
LA375886YH5NMedicare PIN