Provider Demographics
NPI:1295849032
Name:HACKWORTH, LAURA LORRAINE (APRN,CNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LORRAINE
Last Name:HACKWORTH
Suffix:
Gender:F
Credentials:APRN,CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 FULLERTON RD
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2970
Mailing Address - Country:US
Mailing Address - Phone:618-233-7666
Mailing Address - Fax:618-233-7461
Practice Address - Street 1:510 FULLERTON RD
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2970
Practice Address - Country:US
Practice Address - Phone:618-233-7666
Practice Address - Fax:618-233-7461
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209006150363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209006150Medicaid
ILP00372772OtherMEDICARE RR PTAN
IL209006150Medicaid