Provider Demographics
NPI:1578682258
Name:COLSTON, LAURIE LEE (CPNP)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:LEE
Last Name:COLSTON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:LEE
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5812 IMAN PARK CIRCLE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20852
Mailing Address - Country:US
Mailing Address - Phone:240-330-9913
Mailing Address - Fax:
Practice Address - Street 1:4320 DIPLOMACY DR
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5925
Practice Address - Country:US
Practice Address - Phone:907-729-2463
Practice Address - Fax:907-729-2362
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1005098363LP0200X
MDR149149363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4076982 00Medicaid