Healthcare Provider Details

I. General information

NPI: 1285408906
Provider Name (Legal Business Name): AMANDA EADES
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/13/2023
Last Update Date: 11/13/2023
Certification Date: 11/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 HEARNE AVE
SHREVEPORT LA
71103-3917
US

IV. Provider business mailing address

8713 PINEHAVEN DR
KEITHVILLE LA
71047-9774
US

V. Phone/Fax

Practice location:
  • Phone: 318-631-6400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number231615
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: