Provider Demographics
NPI:1922219674
Name:COCKE, KELLI M (MD)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:M
Last Name:COCKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6800 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROUSSARD
Mailing Address - State:LA
Mailing Address - Zip Code:70518-4999
Mailing Address - Country:US
Mailing Address - Phone:337-330-4525
Mailing Address - Fax:337-330-4526
Practice Address - Street 1:6800 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:
Practice Address - City:BROUSSARD
Practice Address - State:LA
Practice Address - Zip Code:70518-4999
Practice Address - Country:US
Practice Address - Phone:337-330-4525
Practice Address - Fax:337-330-4526
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201221208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1214736Medicaid