Provider Demographics
NPI:1588601363
Name:REICHWALD, LAURA ANN (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:REICHWALD
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:REBHANN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 932925
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:31193-2925
Mailing Address - Country:US
Mailing Address - Phone:800-364-9216
Mailing Address - Fax:423-892-5838
Practice Address - Street 1:1455 MONTREAL RD
Practice Address - Street 2:
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-8100
Practice Address - Country:US
Practice Address - Phone:865-985-7253
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051371367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN051371OtherAPN
GAN347264OtherWELLCARE
P00245095OtherRAILROAD MEDICARE
GA000550228DMedicaid
$$$$$$$$$OtherCHAMPUS/TRICARE
GA1982637419Medicare UPIN
GA000550228DMedicaid