Provider Demographics
NPI:1427711464
Name:ANDERSON, STEPHANIE (NP)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 NORMANDY ST
Mailing Address - Street 2:
Mailing Address - City:BARKSDALE AFB
Mailing Address - State:LA
Mailing Address - Zip Code:71110-2328
Mailing Address - Country:US
Mailing Address - Phone:318-458-9300
Mailing Address - Fax:
Practice Address - Street 1:2205 E 70TH ST
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5321
Practice Address - Country:US
Practice Address - Phone:318-797-1585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-17
Last Update Date:2021-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA218916363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care