Provider Demographics
NPI:1033973391
Name:EZERNACK, ANNA MICHELE
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:MICHELE
Last Name:EZERNACK
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 1:252 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71105-3320
Mailing Address - Country:US
Mailing Address - Phone:318-553-6506
Mailing Address - Fax:
Practice Address - Street 1:1800 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4612
Practice Address - Country:US
Practice Address - Phone:318-677-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA203345163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics