Provider Demographics
NPI:1275550055
Name:PAGE, TONI R (APRN)
Entity Type:Individual
Prefix:
First Name:TONI
Middle Name:R
Last Name:PAGE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:TONI
Other - Middle Name:P
Other - Last Name:GUASTELLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:318-675-5000
Mailing Address - Fax:
Practice Address - Street 1:1501 KINGS HWY
Practice Address - Street 2:DEPARTMENT OF PEDIATRICS
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-675-8600
Practice Address - Fax:318-675-8638
Is Sole Proprietor?:No
Enumeration Date:2006-07-16
Last Update Date:2014-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN068449363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1162167Medicaid
LA4C627F600OtherMEDICARE - PTAN
LA4C627F600OtherMEDICARE - PTAN