Provider Demographics
NPI:1336824036
Name:MALDONADO, GEORGINA KATYUSCA
Entity Type:Individual
Prefix:
First Name:GEORGINA
Middle Name:KATYUSCA
Last Name:MALDONADO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 BUNCOMBE RD LOT 51
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71129-9496
Mailing Address - Country:US
Mailing Address - Phone:318-553-0850
Mailing Address - Fax:
Practice Address - Street 1:2100 E 70TH ST STE A
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71105-5363
Practice Address - Country:US
Practice Address - Phone:318-227-4999
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator