Provider Demographics
NPI:1629823794
Name:POUDRIER, KYLEE BROOKE (FNP)
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:BROOKE
Last Name:POUDRIER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:KYLEE
Other - Middle Name:BROOKE
Other - Last Name:BENTON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MAIDEN NAME
Mailing Address - Street 1:3217 MABEL ST
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-4022
Mailing Address - Country:US
Mailing Address - Phone:318-631-9121
Mailing Address - Fax:318-631-9126
Practice Address - Street 1:8383 MILLICENT WAY STE B
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-5207
Practice Address - Country:US
Practice Address - Phone:318-631-9121
Practice Address - Fax:318-213-6246
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-22
Last Update Date:2024-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA235642363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily