Provider Demographics
NPI:1760979512
Name:DEMOURELL, KEYOKA TRINISE
Entity Type:Individual
Prefix:
First Name:KEYOKA
Middle Name:TRINISE
Last Name:DEMOURELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1435 HOLIDAY PL
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70114-1844
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1435 HOLIDAY PL
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70114-1844
Practice Address - Country:US
Practice Address - Phone:504-496-1900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-17
Last Update Date:2018-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA113091163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA$$$$$$$$$Medicaid