Provider Demographics
NPI:1861633943
Name:CORKERN, KELLY B (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:B
Last Name:CORKERN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HIGHWAY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-5763
Mailing Address - Fax:985-867-3644
Practice Address - Street 1:1514 JEFFERSON HIGHWAY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2429
Practice Address - Country:US
Practice Address - Phone:504-842-5763
Practice Address - Fax:985-867-3644
Is Sole Proprietor?:No
Enumeration Date:2009-03-18
Last Update Date:2011-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN111274363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00678509Medicaid
LA1793973Medicaid
LA3B063Medicare PIN