Provider Demographics
NPI:1508803826
Name:MCLARTY, LAURIE L (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:MCLARTY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51213 BAKER RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-3156
Mailing Address - Country:US
Mailing Address - Phone:586-725-7903
Mailing Address - Fax:
Practice Address - Street 1:7733 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3707
Practice Address - Country:US
Practice Address - Phone:313-499-4876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704161919367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAM77150022Medicare PIN