Provider Demographics
NPI:1225002512
Name:HERNDON, LAURIE (GNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:HERNDON
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:WOT 12TH FLOOR ATTN PHYSICIAN SERVICES
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605
Mailing Address - Country:US
Mailing Address - Phone:508-368-5529
Mailing Address - Fax:508-368-5530
Practice Address - Street 1:630 PLANTATION ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01605
Practice Address - Country:US
Practice Address - Phone:508-595-2000
Practice Address - Fax:508-853-7149
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA187387363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0700711Medicaid
042472266008OtherTRICARE CHAMPUS
NP0660OtherBLUE SHIELD INDEMNITY
04247226OtherONE HEALTH PLAN
NP0660OtherBLUE SHIELD HMO BLUE
0700711OtherWELFARE
57676OtherFALLON COMMUNITY HEALTH P
NP0660OtherBLUE CARE ELECT
NP0660OtherMEDICARE B
8300302OtherEVERCARE
AA3450OtherHARVARD PILGRIL HEALTHCAR
NP0660OtherBLUE SHIELD INDEMNITY
57676OtherFALLON COMMUNITY HEALTH P