Healthcare Provider Details

I. General information

NPI: 1861414260
Provider Name (Legal Business Name): KATHLEEN BALLARD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2006
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 KINGS HWY DEPARTMENT OF MEDICINE
SHREVEPORT LA
71103-4228
US

IV. Provider business mailing address

1512 W KIRBY PL
SHREVEPORT LA
71103-3822
US

V. Phone/Fax

Practice location:
  • Phone: 318-675-7636
  • Fax: 318-675-5666
Mailing address:
  • Phone: 318-626-0287
  • Fax: 318-629-4833

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP04387
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: