Provider Demographics
NPI:1427568351
Name:WIDYASTAMI, LAURENSIA HERMY (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:LAURENSIA
Middle Name:HERMY
Last Name:WIDYASTAMI
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61A SUSSEX ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-3011
Mailing Address - Country:US
Mailing Address - Phone:626-232-1421
Mailing Address - Fax:
Practice Address - Street 1:450 STANYAN ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94117-1019
Practice Address - Country:US
Practice Address - Phone:415-680-4135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-05
Last Update Date:2017-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95007344363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner