Provider Demographics
NPI:1881188530
Name:LEUCK, KELLY PATRICIA
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:PATRICIA
Last Name:LEUCK
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 1:1042 CRESSMONT ST
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71111-5759
Mailing Address - Country:US
Mailing Address - Phone:831-246-2088
Mailing Address - Fax:
Practice Address - Street 1:1042 CRESSMONT ST
Practice Address - Street 2:
Practice Address - City:BOSSIER CITY
Practice Address - State:LA
Practice Address - Zip Code:71111-5759
Practice Address - Country:US
Practice Address - Phone:831-246-2088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-17
Last Update Date:2018-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171000000XOther Service ProvidersMilitary Health Care Provider
No251K00000XAgenciesPublic Health or Welfare