Healthcare Provider Details

I. General information

NPI: 1770328734
Provider Name (Legal Business Name): LAKENYA LYRSE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2024
Last Update Date: 07/01/2024
Certification Date: 06/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 LINE AVE
SHREVEPORT LA
71101-4612
US

IV. Provider business mailing address

462 APACHE TRL
SHREVEPORT LA
71107-5412
US

V. Phone/Fax

Practice location:
  • Phone: 318-677-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number235902
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: