Provider Demographics
NPI:1114460995
Name:BRANDENBURG, LAURA L (FNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:L
Last Name:BRANDENBURG
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:HUDDLESTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:670 MASON RIDGE CENTER DR
Mailing Address - Street 2:STE 300
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8573
Mailing Address - Country:US
Mailing Address - Phone:618-463-7777
Mailing Address - Fax:618-463-7767
Practice Address - Street 1:4 MEMORIAL DR
Practice Address - Street 2:STE 230B
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-6751
Practice Address - Country:US
Practice Address - Phone:618-463-7777
Practice Address - Fax:618-463-7767
Is Sole Proprietor?:No
Enumeration Date:2016-11-28
Last Update Date:2016-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209003963363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily