Healthcare Provider Details

I. General information

NPI: 1619343811
Provider Name (Legal Business Name): ALLISON SUPERNEAU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15770 PAUL VEGA MD DR
HAMMOND LA
70403-1475
US

IV. Provider business mailing address

1120 15TH ST # OR2029
AUGUSTA GA
30912-0004
US

V. Phone/Fax

Practice location:
  • Phone: 985-230-1870
  • Fax: 985-230-7461
Mailing address:
  • Phone: 706-721-8623
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number97242
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License Number354386
License Number StateLA
# 3
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License Number009465
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberUO4614
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: