Basic Information
| Provider Information | |||||||||
| NPI: | 1679889224 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GOBERT | ||||||||
| FirstName: | KELLY | ||||||||
| MiddleName: | DUBOIS | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CPNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 209017 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 753200001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8132818478 | ||||||||
| FaxNumber: | 8132818113 | ||||||||
| Practice Location | |||||||||
| Address1: | 3100 SAMFORD AVE | ||||||||
| Address2: | |||||||||
| City: | SHREVEPORT | ||||||||
| State: | LA | ||||||||
| PostalCode: | 711034239 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3182263306 | ||||||||
| FaxNumber: | 3182263319 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 03/27/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | AP06202 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.