Provider Demographics
NPI:1861414260
Name:BALLARD, KATHLEEN (NP)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:BALLARD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-626-0287
Mailing Address - Fax:318-629-4833
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-7636
Practice Address - Fax:318-675-5666
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1581712Medicaid
LA4H091F600OtherMEDICARE - PTAN
LA4H091CC98Medicare PIN
LAQ22232Medicare UPIN