Provider Demographics
NPI:1164975959
Name:KELLY, BRITTANY ELAINE (PA)
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:ELAINE
Last Name:KELLY
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BRITTANY
Other - Middle Name:ELAINE
Other - Last Name:HAMMOND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:8731 PARK PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-5682
Mailing Address - Country:US
Mailing Address - Phone:318-797-5848
Mailing Address - Fax:318-797-5844
Practice Address - Street 1:8731 PARK PLAZA DR
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5682
Practice Address - Country:US
Practice Address - Phone:318-797-5848
Practice Address - Fax:318-797-5844
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-27
Last Update Date:2024-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA303569363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
13922838OtherCAQH