Healthcare Provider Details

I. General information

NPI: 1093466401
Provider Name (Legal Business Name): AMY BETHANY FAVALORA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2022
Last Update Date: 01/17/2022
Certification Date: 01/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ESPLANADE AVE
KENNER LA
70065-2489
US

IV. Provider business mailing address

200 W ESPLANADE AVE
KENNER LA
70065-2489
US

V. Phone/Fax

Practice location:
  • Phone: 985-804-5633
  • Fax:
Mailing address:
  • Phone: 985-804-5633
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number223779
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: