Basic Information
| Provider Information | |||||||||
| NPI: | 1245448208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TALBOT | ||||||||
| FirstName: | AMANDA | ||||||||
| MiddleName: | LAVIGNE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5959 S SHERWOOD FOREST BLVD | ||||||||
| Address2: | |||||||||
| City: | BATON ROUGE | ||||||||
| State: | LA | ||||||||
| PostalCode: | 708166038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2257655727 | ||||||||
| FaxNumber: | 2257659196 | ||||||||
| Practice Location | |||||||||
| Address1: | 4242 HIGHWAY 19 STE C | ||||||||
| Address2: | |||||||||
| City: | ZACHARY | ||||||||
| State: | LA | ||||||||
| PostalCode: | 707913981 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2256546140 | ||||||||
| FaxNumber: | 2256546122 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2007 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 202028 | LA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 1170771 | 05 | LA | MEDICAID |