Provider Demographics
NPI:1023219110
Name:ELLINGTON, AMANDA SUSAN (MD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUSAN
Last Name:ELLINGTON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 122342 DEPT 2342
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70601
Mailing Address - Country:US
Mailing Address - Phone:337-494-2921
Mailing Address - Fax:337-494-6523
Practice Address - Street 1:2770 3RD AVE STE 120
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70601-8994
Practice Address - Country:US
Practice Address - Phone:337-494-4868
Practice Address - Fax:337-494-4870
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2022-06-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA203251208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1099791Medicaid
LAMD.203251OtherSTATE MEDICAL LICENSE