Provider Demographics
NPI:1629353990
Name:CORKERN, KELLI CLEBERT (NP)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:CLEBERT
Last Name:CORKERN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:BRIDGETTE
Other - Last Name:CLEBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5959 S SHERWOOD FOREST BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70816-6038
Mailing Address - Country:US
Mailing Address - Phone:225-526-0001
Mailing Address - Fax:225-765-9196
Practice Address - Street 1:1023 W HIGHWAY 30
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-5002
Practice Address - Country:US
Practice Address - Phone:225-765-5500
Practice Address - Fax:225-647-5342
Is Sole Proprietor?:No
Enumeration Date:2011-10-18
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06551363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07508799Medicaid
LA2169149Medicaid
LA3C857CQ60Medicare PIN
MS07508799Medicaid