Basic Information
| Provider Information | |||||||||
| NPI: | 1922755594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NUNEZ | ||||||||
| FirstName: | KALLIE | ||||||||
| MiddleName: | BROOKE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | OTR | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DUHON | ||||||||
| OtherFirstName: | KALLIE | ||||||||
| OtherMiddleName: | BROOKE | ||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 127 W BROAD ST STE 850 | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706014394 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7277736420 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2701 ERNEST ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CHARLES | ||||||||
| State: | LA | ||||||||
| PostalCode: | 706018406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3374390336 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2022 | ||||||||
| LastUpdateDate: | 03/03/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 02/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | 330219 | LA | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
No ID Information.