Healthcare Provider Details

I. General information

NPI: 1477031763
Provider Name (Legal Business Name): AMANDA M ERWIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/30/2018
Last Update Date: 01/28/2021
Certification Date: 01/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

376 MARKHAM DR
SLIDELL LA
70458-5232
US

IV. Provider business mailing address

409 DOCKSIDE DR
SLIDELL LA
70461-1675
US

V. Phone/Fax

Practice location:
  • Phone: 985-960-7080
  • Fax:
Mailing address:
  • Phone: 985-960-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number194972
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number131366
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: