Provider Demographics
NPI:1386718153
Name:IMUDIA, ANTHONIA N
Entity type:Individual
Prefix:
First Name:ANTHONIA
Middle Name:N
Last Name:IMUDIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 CHATEAU LAFITTE DR W
Mailing Address - Street 2:
Mailing Address - City:KENNER
Mailing Address - State:LA
Mailing Address - Zip Code:70065-1998
Mailing Address - Country:US
Mailing Address - Phone:504-472-9222
Mailing Address - Fax:
Practice Address - Street 1:3715 WILLIAMS BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KENNER
Practice Address - State:LA
Practice Address - Zip Code:70065-3075
Practice Address - Country:US
Practice Address - Phone:504-468-6645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP04583363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily