Provider Demographics
NPI:1548233380
Name:ANKRUM, LAURA J (DO)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:ANKRUM
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75-5751 KUAKINI HWY STE 203
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-1753
Mailing Address - Country:US
Mailing Address - Phone:808-326-5629
Mailing Address - Fax:
Practice Address - Street 1:75-5751 KUAKINI HWY STE 101A
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-1705
Practice Address - Country:US
Practice Address - Phone:808-326-5629
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101014524207Q00000X
WI46621 021207Q00000X
HIDOS-1552207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43512500Medicaid
MI4606364Medicaid
MI4606346Medicaid
HI762543Medicaid
HI762543Medicaid
MI4606364Medicaid