Provider Demographics
NPI:1346378148
Name:FETZER, LAURA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:FETZER
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S. MARYLAND AVENUE, MC 2050
Mailing Address - Street 2:DEPATRTMENT OF GYNECOLOGY
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637
Mailing Address - Country:US
Mailing Address - Phone:773-834-1792
Mailing Address - Fax:773-702-5159
Practice Address - Street 1:5841 S MARYLAND AVE # 2050
Practice Address - Street 2:DEPATRTMENT OF GYNECOLOGY
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60637-1447
Practice Address - Country:US
Practice Address - Phone:773-834-1792
Practice Address - Fax:773-702-5159
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q23611Medicare UPIN
K09683Medicare ID - Type Unspecified