Provider Demographics
NPI:1639642838
Name:SILLAVAN, KIMBERLY DANIELLE (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:DANIELLE
Last Name:SILLAVAN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4702 MONROE HWY
Mailing Address - Street 2:
Mailing Address - City:BALL
Mailing Address - State:LA
Mailing Address - Zip Code:71405-3944
Mailing Address - Country:US
Mailing Address - Phone:318-730-5645
Mailing Address - Fax:
Practice Address - Street 1:4702 MONROE HWY
Practice Address - Street 2:
Practice Address - City:BALL
Practice Address - State:LA
Practice Address - Zip Code:71405-3944
Practice Address - Country:US
Practice Address - Phone:318-641-6113
Practice Address - Fax:318-641-6115
Is Sole Proprietor?:No
Enumeration Date:2019-01-10
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA202489363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2492462Medicaid