MEDICARE: GWENDOLYN KELLY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3747P1801X	Personal Care Attendant

General Provider Information

NPI Number	:	1861897654
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GWENDOLYN KELLY

Provider Business Mailing Address
First Line	:	12097 OLD HAMMOND HWY
Second Line	:	SUITE D-1
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-8679
Country	:	US
Telephone Number	:	225-328-0899
Fax Number	:

Provider Business Practice Location Address
First Line	:	12097 OLD HAMMOND HWY
Second Line	:	SUITE D-1
City	:	BATON ROUGE
State	:	LA
Zip	:	70816-8679
Country	:	US
Telephone Number	:	225-328-0899
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/23/2014
Last Update Date	:	10/23/2014

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Directions to “ GWENDOLYN KELLY ” Practice Location

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