Provider Demographics
NPI:1902896855
Name:WHITAKER, KELLI K (PA)
Entity Type:Individual
Prefix:
First Name:KELLI
Middle Name:K
Last Name:WHITAKER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9118 BLUEBONNET CENTRE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70809-2993
Mailing Address - Country:US
Mailing Address - Phone:225-368-2347
Mailing Address - Fax:225-368-2280
Practice Address - Street 1:6621 FANNIN ST
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77030-2358
Practice Address - Country:US
Practice Address - Phone:225-939-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAA10195363AM0700X
TXPA12104363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1625868Medicaid
LA1625868Medicaid
LAR98195Medicare UPIN