Provider Demographics
NPI:1649770744
Name:SMITH, LAURA A (RN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:SMITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9292 COPPER GREENS CT SE
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49316-8193
Mailing Address - Country:US
Mailing Address - Phone:616-299-9065
Mailing Address - Fax:
Practice Address - Street 1:1853 RW BERENDS DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-4955
Practice Address - Country:US
Practice Address - Phone:616-534-9300
Practice Address - Fax:616-534-9303
Is Sole Proprietor?:No
Enumeration Date:2018-02-15
Last Update Date:2018-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704149052163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669596284Medicaid