Provider Demographics
NPI:1225701790
Name:BLOUNT, AMANDA R (FNP-C)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:R
Last Name:BLOUNT
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:
Other - Last Name:MURRAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 122525 DEPT 2525
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75312-0001
Mailing Address - Country:US
Mailing Address - Phone:337-494-2772
Mailing Address - Fax:337-494-2928
Practice Address - Street 1:1715 WOLF CIR
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-2353
Practice Address - Country:US
Practice Address - Phone:337-480-7499
Practice Address - Fax:337-480-7498
Is Sole Proprietor?:No
Enumeration Date:2021-07-29
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA218673363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA218673OtherSTATE FNP LICENSE
LA2571532Medicaid