Provider Demographics
NPI:1700468691
Name:YOUNGBLOOD, KIERRA DEGALE
Entity Type:Individual
Prefix:
First Name:KIERRA
Middle Name:DEGALE
Last Name:YOUNGBLOOD
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 1:1651 E 70TH ST # 264
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5115
Mailing Address - Country:US
Mailing Address - Phone:318-771-4732
Mailing Address - Fax:318-606-2104
Practice Address - Street 1:3650 LAKESIDE DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71119-6516
Practice Address - Country:US
Practice Address - Phone:318-771-4732
Practice Address - Fax:318-771-4732
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-21
Last Update Date:2021-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN-143657163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WH0200XNursing Service ProvidersRegistered NurseHome HealthGroup - Single Specialty