Healthcare Provider Details

I. General information

NPI: 1205496361
Provider Name (Legal Business Name): ANNA GRACE LIVINGSTON AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2019
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2509 BROADMOOR BLVD STE A
MONROE LA
71201-3184
US

IV. Provider business mailing address

2509 BROADMOOR BLVD STE A
MONROE LA
71201-3184
US

V. Phone/Fax

Practice location:
  • Phone: 318-325-0600
  • Fax: 318-325-0890
Mailing address:
  • Phone: 318-325-0600
  • Fax: 318-325-0890

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number206525
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number206525
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number206525
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: