Provider Demographics
NPI:1477718419
Name:BURNSIDE-MCELLIGOTT, LAURA JEAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:BURNSIDE-MCELLIGOTT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:JEAN
Other - Last Name:MCELLIGOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN, FNP
Mailing Address - Street 1:1890 WAITE ST
Mailing Address - Street 2:STE 1
Mailing Address - City:NORTH BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97459-1229
Mailing Address - Country:US
Mailing Address - Phone:541-756-6232
Mailing Address - Fax:541-756-6234
Practice Address - Street 1:1890 WAITE ST
Practice Address - Street 2:STE 1
Practice Address - City:NORTH BEND
Practice Address - State:OR
Practice Address - Zip Code:97459-1229
Practice Address - Country:US
Practice Address - Phone:541-756-6232
Practice Address - Fax:541-756-6234
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-18
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR081046951RN163W00000X
OR200850064NP FNP-PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR213342Medicaid
OR500617181Medicaid
R163722OtherMEDICARE PTAN
381902Medicare Oscar/Certification