Provider Demographics
NPI:1174344998
Name:MYLES, ANTERRICA GWENA'
Entity type:Individual
Prefix:
First Name:ANTERRICA
Middle Name:GWENA'
Last Name:MYLES
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 1:1088 FRONTAGE RD
Mailing Address - Street 2:
Mailing Address - City:MINDEN
Mailing Address - State:LA
Mailing Address - Zip Code:71055-7861
Mailing Address - Country:US
Mailing Address - Phone:318-588-2147
Mailing Address - Fax:
Practice Address - Street 1:1800 BUCKNER ST STE A206
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4438
Practice Address - Country:US
Practice Address - Phone:318-678-8801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-23
Last Update Date:2024-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA237401363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care