Healthcare Provider Details

I. General information

NPI: 1326048562
Provider Name (Legal Business Name): AMY LYNETTE KISNER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2005
Last Update Date: 12/05/2025
Certification Date: 12/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2647 S SAINT ELIZABETH BLVD STE 308
GONZALES LA
70737-5020
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 225-765-5500
  • Fax: 225-765-9419
Mailing address:
  • Phone: 225-765-5500
  • Fax: 225-765-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number19549
License Number StateWV
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number19549
License Number StateWV
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.204734
License Number StateLA
# 4
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD.204734
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: