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General NPI Number Information
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NPI Number | 1730555046
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Entity Type | Individual
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Provider Name | KOURTNEY KENNEDY GONZALEZ PST. 020858
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Gender | Female
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Dates
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Enumeration Date | 08/20/2015
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Last Update Date | 12/29/2023
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Provider Practice Location Address
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Address Line | 4660 PALMETTO RD STE D
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City | BENTON
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State | LA
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Zip | 71006-9742
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Country | US
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Telephone | 318-965-6211
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Fax |
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Provider Business Mailing Address
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Address Line | 485 MORGAN RD
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City | SAREPTA
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State | LA
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Zip | 71071-2737
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Country | US
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Telephone | 318-422-4349
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 183500000X
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Taxonomy Name | Pharmacist
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License Number | 020858
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License Number State | LA
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