Healthcare Provider Details

I. General information

NPI: 1568967180
Provider Name (Legal Business Name): KELLY NICOLE BREAUX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2018
Last Update Date: 07/29/2024
Certification Date: 07/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 PARK ROWE AVE STE 200
BATON ROUGE LA
70810-1685
US

IV. Provider business mailing address

10101 PARK ROWE AVE STE 200
BATON ROUGE LA
70810-1685
US

V. Phone/Fax

Practice location:
  • Phone: 225-769-2200
  • Fax: 833-756-2680
Mailing address:
  • Phone: 225-769-2200
  • Fax: 833-756-2680

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number343313
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: