Provider Demographics
NPI:1134878184
Name:TRAHAN, AMANDA MOORE (CPHT)
Entity type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:MOORE
Last Name:TRAHAN
Suffix:
Gender:F
Credentials:CPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14086 AIRLINE HWY APT 2423
Mailing Address - Street 2:
Mailing Address - City:GONZALES
Mailing Address - State:LA
Mailing Address - Zip Code:70737-0623
Mailing Address - Country:US
Mailing Address - Phone:803-610-5133
Mailing Address - Fax:
Practice Address - Street 1:14086 AIRLINE HWY APT 2423
Practice Address - Street 2:
Practice Address - City:GONZALES
Practice Address - State:LA
Practice Address - Zip Code:70737-0623
Practice Address - Country:US
Practice Address - Phone:803-610-5133
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
156FX1101X
LA300116203336C0003X, 3336L0003X, 183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183700000XPharmacy Service ProvidersPharmacy TechnicianGroup - Multi-Specialty
No156FX1101XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic AssistantGroup - Multi-Specialty
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
No3336L0003XSuppliersPharmacyLong Term Care Pharmacy