Provider Demographics
NPI:1891366217
Name:DUBOIS, AMY BOATMAN
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:BOATMAN
Last Name:DUBOIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:BOATMAN
Other - Last Name:WISE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:210 MEDICAL DR
Mailing Address - Street 2:
Mailing Address - City:NATCHITOCHES
Mailing Address - State:LA
Mailing Address - Zip Code:71457-6052
Mailing Address - Country:US
Mailing Address - Phone:318-357-3122
Mailing Address - Fax:318-357-3240
Practice Address - Street 1:210 MEDICAL DR
Practice Address - Street 2:
Practice Address - City:NATCHITOCHES
Practice Address - State:LA
Practice Address - Zip Code:71457-6052
Practice Address - Country:US
Practice Address - Phone:318-357-3122
Practice Address - Fax:318-357-3240
Is Sole Proprietor?:No
Enumeration Date:2021-07-07
Last Update Date:2021-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA114204163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1710083Medicaid