Healthcare Provider Details

I. General information

NPI: 1659285559
Provider Name (Legal Business Name): MRS. WANYAN SU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3511 YOUREE DR
SHREVEPORT LA
71105
US

IV. Provider business mailing address

3511 YOUREE DR
SHREVEPORT LA
71105
US

V. Phone/Fax

Practice location:
  • Phone: 318-678-9123
  • Fax:
Mailing address:
  • Phone: 318-678-9123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC20603
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberLA8036
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: