Provider Demographics
NPI:1750364428
Name:NOVAK, KELLY VALENTINE (F N P)
Entity type:Individual
Prefix:MRS
First Name:KELLY
Middle Name:VALENTINE
Last Name:NOVAK
Suffix:
Gender:F
Credentials:F N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 OAK LEAF TRL
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:LA
Mailing Address - Zip Code:71006-9600
Mailing Address - Country:US
Mailing Address - Phone:318-965-4759
Mailing Address - Fax:318-965-3840
Practice Address - Street 1:8001 YOUREE DR
Practice Address - Street 2:SUITE 880
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71115-2302
Practice Address - Country:US
Practice Address - Phone:318-798-3328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-27
Last Update Date:2014-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04759363LF0000X
LAPA 020646363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily