Provider Demographics
NPI:1962995688
Name:ELMORE, KANITRA
Entity type:Individual
Prefix:
First Name:KANITRA
Middle Name:
Last Name:ELMORE
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 1:2984 HIGHWAY 80 W LOT 58
Mailing Address - Street 2:
Mailing Address - City:CALHOUN
Mailing Address - State:LA
Mailing Address - Zip Code:71225-7915
Mailing Address - Country:US
Mailing Address - Phone:318-552-5126
Mailing Address - Fax:318-552-5127
Practice Address - Street 1:202 LAKE ST
Practice Address - Street 2:
Practice Address - City:LAKE PROVIDENCE
Practice Address - State:LA
Practice Address - Zip Code:71254-2628
Practice Address - Country:US
Practice Address - Phone:318-552-5126
Practice Address - Fax:318-552-5127
Is Sole Proprietor?:No
Enumeration Date:2018-06-07
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA111966163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse