Healthcare Provider Details

I. General information

NPI: 1568074565
Provider Name (Legal Business Name): CARLA CUNNINGHAM TYNES RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 ASHLEY RIDGE BLVD STE 500
SHREVEPORT LA
71106-7238
US

IV. Provider business mailing address

460 ASHLEY RIDGE BLVD STE 500
SHREVEPORT LA
71106-7238
US

V. Phone/Fax

Practice location:
  • Phone: 318-820-8078
  • Fax:
Mailing address:
  • Phone: 318-820-8078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License NumberRN037324
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: