Provider Demographics
NPI:1891385787
Name:HODGE, KELLEN GLYN (RN, CCM)
Entity Type:Individual
Prefix:MR
First Name:KELLEN
Middle Name:GLYN
Last Name:HODGE
Suffix:
Gender:M
Credentials:RN, CCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:215 JETT RD
Mailing Address - Street 2:
Mailing Address - City:HORNBECK
Mailing Address - State:LA
Mailing Address - Zip Code:71439-1423
Mailing Address - Country:US
Mailing Address - Phone:337-322-9878
Mailing Address - Fax:337-531-3428
Practice Address - Street 1:1585 3RD ST
Practice Address - Street 2:
Practice Address - City:FORT POLK
Practice Address - State:LA
Practice Address - Zip Code:71459-5102
Practice Address - Country:US
Practice Address - Phone:337-531-3068
Practice Address - Fax:337-531-3428
Is Sole Proprietor?:No
Enumeration Date:2021-01-25
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN115467163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management