Healthcare Provider Details

I. General information

NPI: 1235452822
Provider Name (Legal Business Name): AMANDA VERKRUISSEN BURNETT ANP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2010
Last Update Date: 04/27/2022
Certification Date: 04/27/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 OAK PARK BLVD FL 1
LAKE CHARLES LA
70601-8977
US

IV. Provider business mailing address

PO BOX 122205 DEPT 2205
DALLAS TX
75312-2205
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-6800
  • Fax: 337-494-6761
Mailing address:
  • Phone: 337-494-2772
  • Fax: 337-494-2928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP0071
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: