Provider Demographics
NPI:1104215573
Name:BOOKER, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOOKER
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 1:12525 RENAISSANCE CIR
Mailing Address - Street 2:
Mailing Address - City:HOMER GLEN
Mailing Address - State:IL
Mailing Address - Zip Code:60491-5896
Mailing Address - Country:US
Mailing Address - Phone:708-590-5050
Mailing Address - Fax:
Practice Address - Street 1:12525 RENAISSANCE CIR
Practice Address - Street 2:
Practice Address - City:HOMER GLEN
Practice Address - State:IL
Practice Address - Zip Code:60491-5896
Practice Address - Country:US
Practice Address - Phone:708-590-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator
Provider Identifiers
StateIdentifier IDID TypeIssuer
143027Medicare UPIN