Provider Demographics
NPI:1831612415
Name:BORDELON JEANSONNE, KRISTEN (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:BORDELON JEANSONNE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:MICHELLE
Other - Last Name:BORDELON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1007 SYCAMORE ST STE B
Mailing Address - Street 2:
Mailing Address - City:COTTONPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71327-3403
Mailing Address - Country:US
Mailing Address - Phone:800-462-0742
Mailing Address - Fax:318-964-2554
Practice Address - Street 1:1007 SYCAMORE ST STE B
Practice Address - Street 2:
Practice Address - City:COTTONPORT
Practice Address - State:LA
Practice Address - Zip Code:71327-3403
Practice Address - Country:US
Practice Address - Phone:800-462-0742
Practice Address - Fax:318-964-2554
Is Sole Proprietor?:No
Enumeration Date:2017-07-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP09522363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2452657Medicaid