Basic Information
| Provider Information | |||||||||
| NPI: | 1952706897 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GOLDBERG | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | RICHARD | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MN, APRN, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RICHARD | ||||||||
| OtherFirstName: | AMANDA | ||||||||
| OtherMiddleName: | RUTH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 148 WALL BLVD | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700567107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043932273 | ||||||||
| FaxNumber: | 5043932744 | ||||||||
| Practice Location | |||||||||
| Address1: | 148 WALL BLVD | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 700567107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5043932273 | ||||||||
| FaxNumber: | 5043932744 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2014 | ||||||||
| LastUpdateDate: | 05/09/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN123165 | LA | N | Nursing Service Providers | Registered Nurse | 363LF0000X | AP08005 | LA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.