Healthcare Provider Details

I. General information

NPI: 1669380929
Provider Name (Legal Business Name): MRS. MICHELLE DOUGLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1800 LINE AVE
SHREVEPORT LA
71101-4612
US

IV. Provider business mailing address

8405 E WILDERNESS WAY
SHREVEPORT LA
71106-6128
US

V. Phone/Fax

Practice location:
  • Phone: 318-357-6011
  • Fax:
Mailing address:
  • Phone: 318-934-2819
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number209194
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: