Provider Demographics
NPI:1609036466
Name:LEA, AMANDA RIDDELL (DO)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:RIDDELL
Last Name:LEA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2335 CHURCH ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-2700
Mailing Address - Country:US
Mailing Address - Phone:225-654-3607
Mailing Address - Fax:225-658-2262
Practice Address - Street 1:2335 CHURCH ST
Practice Address - Street 2:SUITE E
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-2700
Practice Address - Country:US
Practice Address - Phone:225-654-3607
Practice Address - Fax:225-658-2262
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2020-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LADO.000325207R00000X
MS20285207R00000X
MO2008008953207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2345711Medicaid