Provider Demographics
NPI:1558665109
Name:MOUTHAAN, LARAINE M (ARNP)
Entity Type:Individual
Prefix:
First Name:LARAINE
Middle Name:M
Last Name:MOUTHAAN
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4371 VERONICA S SHOEMAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33916-2216
Mailing Address - Country:US
Mailing Address - Phone:239-274-8200
Mailing Address - Fax:239-278-3350
Practice Address - Street 1:3840 BROADWAY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33901-8108
Practice Address - Country:US
Practice Address - Phone:239-275-6400
Practice Address - Fax:239-275-0178
Is Sole Proprietor?:No
Enumeration Date:2010-12-22
Last Update Date:2011-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2699572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner