Healthcare Provider Details

I. General information

NPI: 1831011469
Provider Name (Legal Business Name): KELLY FONTENOT CAMPBELL FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2026
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 W GAUTHIER RD
LAKE CHARLES LA
70605-7170
US

IV. Provider business mailing address

PO BOX 122585 DEPT 2585
DALLAS TX
75312-0001
US

V. Phone/Fax

Practice location:
  • Phone: 337-480-7030
  • Fax:
Mailing address:
  • Phone: 337-480-7030
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number248523
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: