Provider Demographics
NPI:1164634697
Name:WELLS, LAURA L (NP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:L
Last Name:WELLS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:L
Other - Last Name:JOLLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:4136 LARAMIE ST
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82001-2086
Mailing Address - Country:US
Mailing Address - Phone:307-212-6270
Mailing Address - Fax:307-212-6271
Practice Address - Street 1:4136 LARAMIE ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-2086
Practice Address - Country:US
Practice Address - Phone:307-212-6270
Practice Address - Fax:307-212-6271
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0005165-NP363LF0000X
WI8847363LF0000X
OR201403551NP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO128906OtherREGISTERED NURSE
WI1164634697Medicaid