Healthcare Provider Details

I. General information

NPI: 1376522425
Provider Name (Legal Business Name): KELLY LINER DUKE P.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2006
Last Update Date: 03/07/2023
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 S SAINT ELIZABETH BLVD STE 125
GONZALES LA
70737-5020
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-647-9675
  • Fax: 225-766-2226
Mailing address:
  • Phone: 225-526-0001
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number200058
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: