Healthcare Provider Details

I. General information

NPI: 1508216433
Provider Name (Legal Business Name): KELLIE HAVER B.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2016
Last Update Date: 12/20/2024
Certification Date: 12/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3867 PLAZA TOWER DR FL TOWERDR1
BATON ROUGE LA
70816-4378
US

IV. Provider business mailing address

513B E FAIRFIELD DR
BROUSSARD LA
70518-5303
US

V. Phone/Fax

Practice location:
  • Phone: 337-239-3334
  • Fax: 337-239-3334
Mailing address:
  • Phone: 337-251-0195
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number1299
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: