Provider Demographics
NPI:1134493695
Name:NELSON, KALISHA ANTONIA (DDS)
Entity type:Individual
Prefix:DR
First Name:KALISHA
Middle Name:ANTONIA
Last Name:NELSON
Suffix:
Gender:F
Credentials:DDS
Other - Prefix:DR
Other - First Name:KALISHA
Other - Middle Name:
Other - Last Name:NELSON HANLEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DDS
Mailing Address - Street 1:1151 MARGUERITE ST STE 100A
Mailing Address - Street 2:
Mailing Address - City:MORGAN CITY
Mailing Address - State:LA
Mailing Address - Zip Code:70380-1881
Mailing Address - Country:US
Mailing Address - Phone:985-255-4524
Mailing Address - Fax:985-255-4546
Practice Address - Street 1:1151 MARGUERITE ST STE 100A
Practice Address - Street 2:
Practice Address - City:MORGAN CITY
Practice Address - State:LA
Practice Address - Zip Code:70380-1881
Practice Address - Country:US
Practice Address - Phone:985-255-4524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-01
Last Update Date:2024-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA6724122300000X, 1223G0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty
No122300000XDental ProvidersDentist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1867241Medicaid
LA1A5073OtherMEDICARE