Provider Demographics
NPI:1285200618
Name:HORNE, ETHAN (LPN)
Entity Type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:HORNE
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5301 MEADOWSWEET CIR
Mailing Address - Street 2:
Mailing Address - City:BOSSIER CITY
Mailing Address - State:LA
Mailing Address - Zip Code:71112-8645
Mailing Address - Country:US
Mailing Address - Phone:318-230-2270
Mailing Address - Fax:
Practice Address - Street 1:3341 YOUREE DR STE 205
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-2149
Practice Address - Country:US
Practice Address - Phone:318-219-4167
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-27
Last Update Date:2021-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA20190021164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse