Provider Demographics
NPI:1598160608
Name:WEDERTZ, LAURA (CRNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:WEDERTZ
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2461 BRADDOCK RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT AIRY
Mailing Address - State:MD
Mailing Address - Zip Code:21771-8801
Mailing Address - Country:US
Mailing Address - Phone:434-340-5962
Mailing Address - Fax:
Practice Address - Street 1:194 THOMAS JOHNSON DR
Practice Address - Street 2:
Practice Address - City:FREDERICK
Practice Address - State:MD
Practice Address - Zip Code:21702-4679
Practice Address - Country:US
Practice Address - Phone:240-215-6370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR185929363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily