Healthcare Provider Details

I. General information

NPI: 1952706897
Provider Name (Legal Business Name): AMANDA RICHARD GOLDBERG MN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMANDA RUTH RICHARD

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 05/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

148 WALL BLVD
GRETNA LA
70056-7107
US

IV. Provider business mailing address

148 WALL BLVD
GRETNA LA
70056-7107
US

V. Phone/Fax

Practice location:
  • Phone: 504-393-2273
  • Fax: 504-393-2744
Mailing address:
  • Phone: 504-393-2273
  • Fax: 504-393-2744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP08005
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN123165
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: