Basic Information
| Provider Information | |||||||||
| NPI: | 1225640980 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARSHALL | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 CORPORATE BLVD | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 705083870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8008939698 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207453 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238441121 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/23/2020 | ||||||||
| LastUpdateDate: | 07/14/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 28250 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 163WE0003X | 203805 | TN | N | Nursing Service Providers | Registered Nurse | Emergency | 363LC0200X | 28250 | TN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Critical Care Medicine |
No ID Information.