Healthcare Provider Details

I. General information

NPI: 1760822589
Provider Name (Legal Business Name): AMY LYNN MAUTNER CSFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2013
Last Update Date: 06/13/2020
Certification Date: 06/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

273 HOLLYWOOD DR
METAIRIE LA
70005-3919
US

IV. Provider business mailing address

273 HOLLYWOOD DR
METAIRIE LA
70005-3919
US

V. Phone/Fax

Practice location:
  • Phone: 504-905-7456
  • Fax:
Mailing address:
  • Phone: 504-905-7456
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License NumberSA0185
License Number StateDC
# 2
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number124157
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: