Provider Demographics
NPI:1679889224
Name:GOBERT, KELLY DUBOIS (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:DUBOIS
Last Name:GOBERT
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 209017
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-0001
Mailing Address - Country:US
Mailing Address - Phone:813-281-8478
Mailing Address - Fax:813-281-8113
Practice Address - Street 1:3100 SAMFORD AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4239
Practice Address - Country:US
Practice Address - Phone:318-226-3306
Practice Address - Fax:318-226-3319
Is Sole Proprietor?:No
Enumeration Date:2010-08-20
Last Update Date:2012-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP06202363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics