Provider Demographics
NPI:1053726752
Name:LEWIS, AMANDA LANE (FNP)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:LANE
Last Name:LEWIS
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP STE 105
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71118-3175
Mailing Address - Country:US
Mailing Address - Phone:318-797-2328
Mailing Address - Fax:318-212-5674
Practice Address - Street 1:2508 BERT KOUNS INDUSTRIAL LOOP STE 105
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3175
Practice Address - Country:US
Practice Address - Phone:318-797-2328
Practice Address - Fax:318-212-5674
Is Sole Proprietor?:No
Enumeration Date:2014-06-23
Last Update Date:2023-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP07873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2401521Medicaid