Provider Demographics
NPI:1457552424
Name:ESTAPA, AMANDA HERRICK (ACNP)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:HERRICK
Last Name:ESTAPA
Suffix:
Gender:F
Credentials:ACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1089
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-1089
Mailing Address - Country:US
Mailing Address - Phone:985-892-7070
Mailing Address - Fax:
Practice Address - Street 1:16065 LAMONTE DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1405
Practice Address - Country:US
Practice Address - Phone:985-892-7070
Practice Address - Fax:985-892-7017
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN095442363L00000X
LAAP05167363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1012131Medicaid
MS00687066Medicaid
LA3A322Medicare PIN