Provider Demographics
NPI:1730660812
Name:KERRY, ROSE MICHELLE
Entity Type:Individual
Prefix:MS
First Name:ROSE
Middle Name:MICHELLE
Last Name:KERRY
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:ROSE
Other - Middle Name:MICHELLE
Other - Last Name:WYLL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:BA
Mailing Address - Street 1:2525 YOUREE DR STE 110
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71104-3600
Mailing Address - Country:US
Mailing Address - Phone:318-675-0804
Mailing Address - Fax:318-425-9030
Practice Address - Street 1:1450 PETERMAN DR STE A
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3432
Practice Address - Country:US
Practice Address - Phone:318-473-4328
Practice Address - Fax:318-473-4329
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2018-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator