Provider Demographics
NPI:1811795362
Name:KELLY, LETOSHA SHEPARD
Entity type:Individual
Prefix:MRS
First Name:LETOSHA
Middle Name:SHEPARD
Last Name:KELLY
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 1:15641 JOOR RD
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-8806
Mailing Address - Country:US
Mailing Address - Phone:225-485-7952
Mailing Address - Fax:
Practice Address - Street 1:15641 JOOR RD
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-8806
Practice Address - Country:US
Practice Address - Phone:225-485-7952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver