Healthcare Provider Details

I. General information

NPI: 1225849524
Provider Name (Legal Business Name): ELIZABETH GRACE MCKELLAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2025
Last Update Date: 01/15/2025
Certification Date: 01/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2924 KNIGHT ST STE 369
SHREVEPORT LA
71105-2413
US

IV. Provider business mailing address

171 PENNSYLVANIA AVE
SHREVEPORT LA
71105-3317
US

V. Phone/Fax

Practice location:
  • Phone: 318-210-0587
  • Fax:
Mailing address:
  • Phone: 318-990-2001
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: