Provider Demographics
NPI:1427867316
Name:DERISE, KELLY M
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:M
Last Name:DERISE
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 1:423 OAK MANOR DR
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70563-2243
Mailing Address - Country:US
Mailing Address - Phone:337-380-0161
Mailing Address - Fax:
Practice Address - Street 1:1900 GRAVIER ST
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70112-2262
Practice Address - Country:US
Practice Address - Phone:504-568-4106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-06
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA205692163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine