Provider Demographics
NPI:1790276004
Name:MORAN, KEYONNA
Entity Type:Individual
Prefix:
First Name:KEYONNA
Middle Name:
Last Name:MORAN
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 1:1746 COCO BED RD
Mailing Address - Street 2:
Mailing Address - City:CLOUTIERVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71416-2250
Mailing Address - Country:US
Mailing Address - Phone:318-471-2918
Mailing Address - Fax:
Practice Address - Street 1:4000 AIRLINE DR STE 1
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-2042
Practice Address - Country:US
Practice Address - Phone:318-588-5012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-22
Last Update Date:2018-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator