Healthcare Provider Details

I. General information

NPI: 1578450904
Provider Name (Legal Business Name): AMY BROOKE BORDELON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2025
Last Update Date: 06/19/2025
Certification Date: 06/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3312 KALISTE SALOOM RD
LAFAYETTE LA
70508-7449
US

IV. Provider business mailing address

3312 KALISTE SALOOM RD
LAFAYETTE LA
70508-7449
US

V. Phone/Fax

Practice location:
  • Phone: 337-237-0788
  • Fax:
Mailing address:
  • Phone: 337-237-0788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number241901
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: