Provider Demographics
NPI:1124317524
Name:MELANCON, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:MELANCON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2424 WILLIAMS BLVD
Mailing Address - Street 2:SUITE A AND B
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70062-5763
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2424 WILLIAMS BLVD
Practice Address - Street 2:SUITE A AND B
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70062-5763
Practice Address - Country:US
Practice Address - Phone:504-464-0719
Practice Address - Fax:504-464-0721
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-06
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1591111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor