Provider Demographics
NPI:1770748097
Name:ROUSSELL, KENEITRA BROWN (PA-C)
Entity type:Individual
Prefix:DR
First Name:KENEITRA
Middle Name:BROWN
Last Name:ROUSSELL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3584 W AIRLINE HWY
Mailing Address - Street 2:
Mailing Address - City:RESERVE
Mailing Address - State:LA
Mailing Address - Zip Code:70084-5708
Mailing Address - Country:US
Mailing Address - Phone:985-200-3836
Mailing Address - Fax:
Practice Address - Street 1:3584 W AIRLINE HWY
Practice Address - Street 2:
Practice Address - City:RESERVE
Practice Address - State:LA
Practice Address - Zip Code:70084-5708
Practice Address - Country:US
Practice Address - Phone:985-200-3836
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-25
Last Update Date:2025-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAPA200279207R00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAPA.200279OtherLOUISIANA STATE BOARD OF MEDICAL EXAMINERS
LA56868PB59Medicare PIN