Provider Demographics
NPI:1093749343
Name:LARAWAY, JACQUELINE (ACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:
Last Name:LARAWAY
Suffix:
Gender:F
Credentials:ACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:245 MEDICAL PARK DR
Mailing Address - Street 2:FIRST FLOOR
Mailing Address - City:MARION
Mailing Address - State:VA
Mailing Address - Zip Code:24354-1100
Mailing Address - Country:US
Mailing Address - Phone:276-378-1341
Mailing Address - Fax:276-378-1205
Practice Address - Street 1:245 MEDICAL PARK DR
Practice Address - Street 2:FIRST FLOOR
Practice Address - City:MARION
Practice Address - State:VA
Practice Address - Zip Code:24354-1100
Practice Address - Country:US
Practice Address - Phone:276-378-1341
Practice Address - Fax:276-378-1205
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167734363LA2100X
TN13443363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1093749343Medicaid
VAP00681428OtherRR MEDICARE
TN1507124Medicaid
VADF7910OtherRR MEDICARE
VAP00681428OtherRR MEDICARE
VA1093749343Medicaid
VAMC10084Medicare PIN