Healthcare Provider Details

I. General information

NPI: 1912377110
Provider Name (Legal Business Name): AMBER PETREY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 S CLEARVIEW PKWY
JEFFERSON LA
70121-1015
US

IV. Provider business mailing address

1461 2ND ST
LUTCHER LA
70071-5505
US

V. Phone/Fax

Practice location:
  • Phone: 225-206-0992
  • Fax:
Mailing address:
  • Phone: 225-206-0992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberATH.200135
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: