Provider Demographics
NPI:1780068106
Name:PARKER, KEYLA
Entity type:Individual
Prefix:
First Name:KEYLA
Middle Name:
Last Name:PARKER
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 1:12224 KINGSTON DR
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70807-2072
Mailing Address - Country:US
Mailing Address - Phone:225-978-8601
Mailing Address - Fax:
Practice Address - Street 1:58026 FORT ST
Practice Address - Street 2:
Practice Address - City:PLAQUEMINE
Practice Address - State:LA
Practice Address - Zip Code:70764-3222
Practice Address - Country:US
Practice Address - Phone:225-685-1163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2015-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA261QM0801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA600723334OtherSEASIDE