Provider Demographics
NPI:1033973391
Name:EZERNACK, ANNA MICHELE (NP)
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MICHELE
Last Name:EZERNACK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1111 LINE AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-3841
Mailing Address - Country:US
Mailing Address - Phone:318-716-4610
Mailing Address - Fax:318-716-4690
Practice Address - Street 1:1111 LINE AVE FL 3
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3841
Practice Address - Country:US
Practice Address - Phone:318-716-4610
Practice Address - Fax:318-716-4690
Is Sole Proprietor?:No
Enumeration Date:2024-02-07
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA203345163WP0200X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0200XNursing Service ProvidersRegistered NursePediatrics