| Doctor Name: | KERRI LUCKEN TYNES |
| NPI Number: | 1104004720 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | P.A. |
| License Number: | A10314 |
| Business Practice Address: | 2300 Hospital Dr Suite 450 Bossier City, LA - 711112394 |
| Business Phone Number: | 3187522328 |
| Business Fax Number: | 3187460160 |
| Mailing Address: | 2727 Hearne Ave, Suite 301 SHREVEPORT |
| State: | LA |
| Postal Code: | 711033931 |
| Phone Number: | 3186316400 |
| Fax Number: | 3186310300 |
| NPI Enumeration Date: | 02/06/2008 |
| NPI Last Update Date: | 02/06/2008 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AM0700X |
| License Number: | A10314 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | LA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Medical |
| Taxonomy Definition: | |