Provider Demographics
NPI:1326047358
Name:FORD, LAURA CATHERINE (CNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:CATHERINE
Last Name:FORD
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52375 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MATTAWAN
Mailing Address - State:MI
Mailing Address - Zip Code:49071-9332
Mailing Address - Country:US
Mailing Address - Phone:269-668-3348
Mailing Address - Fax:269-668-7702
Practice Address - Street 1:52375 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MATTAWAN
Practice Address - State:MI
Practice Address - Zip Code:49071-9332
Practice Address - Country:US
Practice Address - Phone:269-668-3348
Practice Address - Fax:269-668-7702
Is Sole Proprietor?:No
Enumeration Date:2005-07-20
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704134722363L00000X, 363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI114987799Medicaid
MI114987799Medicaid
MI0H06012018Medicare PIN