Healthcare Provider Details

I. General information

NPI: 1023219110
Provider Name (Legal Business Name): AMANDA SUSAN ELLINGTON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2007
Last Update Date: 06/09/2022
Certification Date: 06/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2770 3RD AVE STE 120
LAKE CHARLES LA
70601-8994
US

IV. Provider business mailing address

P.O. BOX 122342 DEPT 2342
LAKE CHARLES LA
70601
US

V. Phone/Fax

Practice location:
  • Phone: 337-494-4868
  • Fax: 337-494-4870
Mailing address:
  • Phone: 337-494-2921
  • Fax: 337-494-6523

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number203251
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: