Provider Demographics
NPI:1962049320
Name:FRIDAY, KELBY
Entity type:Individual
Prefix:
First Name:KELBY
Middle Name:
Last Name:FRIDAY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:638 BAY CITY RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH
Mailing Address - State:LA
Mailing Address - Zip Code:70638-4009
Mailing Address - Country:US
Mailing Address - Phone:318-623-9335
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-623-9335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-04
Last Update Date:2019-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN158940163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse