Provider Demographics
NPI:1407286784
Name:FORD, LAURA (ARNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FORD
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANNE
Other - Last Name:GORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11661 NW FORD FARM TRL
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:FL
Mailing Address - Zip Code:32321-1720
Mailing Address - Country:US
Mailing Address - Phone:850-237-3000
Mailing Address - Fax:850-237-3001
Practice Address - Street 1:20370 NE BURNS AVE
Practice Address - Street 2:
Practice Address - City:BLOUNTSTOWN
Practice Address - State:FL
Practice Address - Zip Code:32424-1045
Practice Address - Country:US
Practice Address - Phone:850-237-3000
Practice Address - Fax:850-237-3001
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-22
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN9229205163W00000X
FLARNP9229205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010460500Medicaid