Healthcare Provider Details

I. General information

NPI: 1548764327
Provider Name (Legal Business Name): KELSEY HERSHEY MANGUNO MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 12/02/2024
Certification Date: 12/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5025 KEYSTONE BLVD STE 100
COVINGTON LA
70433-7526
US

IV. Provider business mailing address

200 HENRY CLAY AVE
NEW ORLEANS LA
70118-5720
US

V. Phone/Fax

Practice location:
  • Phone: 985-893-3395
  • Fax: 985-892-8212
Mailing address:
  • Phone: 504-894-6783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number326106
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: