Provider Demographics
NPI:1326023672
Name:LANDRY, AMY W (CRNA)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:W
Last Name:LANDRY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 KALISTE SALOOM RD
Mailing Address - Street 2:SUITE 304
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-5783
Mailing Address - Country:US
Mailing Address - Phone:337-988-5646
Mailing Address - Fax:337-988-4298
Practice Address - Street 1:1103 KALISTE SALOOM RD
Practice Address - Street 2:SUITE 304
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-5783
Practice Address - Country:US
Practice Address - Phone:337-988-5646
Practice Address - Fax:337-988-4298
Is Sole Proprietor?:No
Enumeration Date:2005-12-09
Last Update Date:2010-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAAP01528367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1981788Medicaid
LA5T148Medicare PIN