Healthcare Provider Details

I. General information

NPI: 1699695445
Provider Name (Legal Business Name): KATELYN GRACE THOMPSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2026
Last Update Date: 07/20/2026
Certification Date: 07/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 LINE AVE
SHREVEPORT LA
71101-4612
US

IV. Provider business mailing address

1507 GARLAND PL
SHREVEPORT LA
71105-5708
US

V. Phone/Fax

Practice location:
  • Phone: 318-677-3100
  • Fax:
Mailing address:
  • Phone: 334-405-3298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number976721
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: