Provider Demographics
NPI:1114202934
Name:FORD, LAURA JEAN (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:FORD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 660857
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0857
Mailing Address - Country:US
Mailing Address - Phone:972-715-5000
Mailing Address - Fax:
Practice Address - Street 1:13601 PRESTON RD
Practice Address - Street 2:SUITE 1000W
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75240-4911
Practice Address - Country:US
Practice Address - Phone:972-715-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-12
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704285066367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4308718480OtherBCBS
MIP01015922OtherRAILROAD MEDICARE
MI1114202934Medicaid
MI1114202934Medicaid