Healthcare Provider Details

I. General information

NPI: 1780802504
Provider Name (Legal Business Name): HEALING GRACE INTERNAL MEDICINE & PEDIATRICS, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6821 PINES RD SUITE 200
SHREVEPORT LA
71129-2547
US

IV. Provider business mailing address

6821 PINES RD SUITE 200
SHREVEPORT LA
71129-2547
US

V. Phone/Fax

Practice location:
  • Phone: 318-671-9309
  • Fax: 318-671-9311
Mailing address:
  • Phone: 318-671-9309
  • Fax: 318-671-9311

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number023335
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number023335
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number023335
License Number StateLA

VIII. Authorized Official

Name: TONYA CLAYTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 318-671-9309