Provider Demographics
NPI:1871113829
Name:NAMMOUR, ANNA GRACE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:GRACE
Last Name:NAMMOUR
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 1:1512 W KIRBY PL
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71103-3822
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1541 KINGS HWY
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71103-4228
Practice Address - Country:US
Practice Address - Phone:318-626-0000
Practice Address - Fax:318-629-4833
Is Sole Proprietor?:No
Enumeration Date:2020-04-20
Last Update Date:2023-06-12
Deactivation Date:2020-05-20
Deactivation Code:
Reactivation Date:2020-07-14
Provider Licenses
StateLicense IDTaxonomies
LA336067207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine