Healthcare Provider Details

I. General information

NPI: 1518450105
Provider Name (Legal Business Name): AMANDA MICHELLE LEWIS FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 06/22/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1453 E BERT KOUN LOOP STE 112
SHREVEPORT LA
71105-6810
US

IV. Provider business mailing address

PO BOX 51008
SHREVEPORT LA
71135-1008
US

V. Phone/Fax

Practice location:
  • Phone: 318-798-9400
  • Fax: 318-222-3757
Mailing address:
  • Phone: 318-798-9400
  • Fax: 318-424-0717

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP09963
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: