Provider Demographics
NPI:1629045752
Name:LAURA, ANTOINETTE (NP)
Entity Type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:LAURA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1009 N AVALON BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-4505
Mailing Address - Country:US
Mailing Address - Phone:310-549-5760
Mailing Address - Fax:
Practice Address - Street 1:1009 N AVALON BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-4505
Practice Address - Country:US
Practice Address - Phone:310-549-5760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8978363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ16598Medicare UPIN
CAZZZ03097ZMedicare PIN