Provider Demographics
NPI:1780268516
Name:POULLARD, KYLAN
Entity type:Individual
Prefix:
First Name:KYLAN
Middle Name:
Last Name:POULLARD
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 WINDERMERE BLVD
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:LA
Mailing Address - Zip Code:71303-3538
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3311 PRESCOTT RD STE 415
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-3985
Practice Address - Country:US
Practice Address - Phone:318-528-4455
Practice Address - Fax:318-528-4466
Is Sole Proprietor?:No
Enumeration Date:2021-05-07
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
LA327294363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant