Provider Demographics
NPI:1427184126
Name:LACOMB, AMANDA MARIE (MD)
Entity Type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:MARIE
Last Name:LACOMB
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:MARIE
Other - Last Name:LACOMB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 719
Mailing Address - Street 2:
Mailing Address - City:JENNINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70546-0719
Mailing Address - Country:US
Mailing Address - Phone:337-824-8868
Mailing Address - Fax:337-824-8829
Practice Address - Street 1:1322 ELTON RD
Practice Address - Street 2:SUITE F
Practice Address - City:JENNINGS
Practice Address - State:LA
Practice Address - Zip Code:70546-4138
Practice Address - Country:US
Practice Address - Phone:337-824-8868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2011-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA023135207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1491667Medicaid
LA1491667Medicaid
LAG68142Medicare UPIN