Healthcare Provider Details

I. General information

NPI: 1659016673
Provider Name (Legal Business Name): TONYA DENISE DEAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2022
Last Update Date: 12/13/2022
Certification Date: 12/13/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8932 JEWELLA AVE STE A
SHREVEPORT LA
71118-2117
US

IV. Provider business mailing address

5896 SUNSET TRACE DR
KEITHVILLE LA
71047-5402
US

V. Phone/Fax

Practice location:
  • Phone: 318-572-9756
  • Fax:
Mailing address:
  • Phone: 318-572-9756
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: