Healthcare Provider Details

I. General information

NPI: 1376197194
Provider Name (Legal Business Name): KEELEY CLAIRE RUSS APRN-CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/30/2019
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1105 HUDSON LN
MONROE LA
71201-6003
US

IV. Provider business mailing address

394 FOREST CIR
RUSTON LA
71270-2666
US

V. Phone/Fax

Practice location:
  • Phone: 318-322-6500
  • Fax: 318-322-5118
Mailing address:
  • Phone: 318-548-4066
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number207481
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: