Healthcare Provider Details

I. General information

NPI: 1093218547
Provider Name (Legal Business Name): ASHLEY ANDERSON PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ASHLEY SOUTHER

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2104 LOOP RD STE C
WINNSBORO LA
71295-3341
US

IV. Provider business mailing address

PO BOX 1300
WINNSBORO LA
71295-1300
US

V. Phone/Fax

Practice location:
  • Phone: 318-435-4571
  • Fax:
Mailing address:
  • Phone: 318-412-5265
  • Fax: 318-435-3842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number12312341
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: