Provider Demographics
NPI:1659600286
Name:HERBERT, LAURA JEAN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:JEAN
Last Name:HERBERT
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4787 KINGS RIDGE CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRBORN
Mailing Address - State:OH
Mailing Address - Zip Code:45324-1862
Mailing Address - Country:US
Mailing Address - Phone:937-760-7667
Mailing Address - Fax:
Practice Address - Street 1:2633 COMMONS BLVD
Practice Address - Street 2:SUITE 120
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3827
Practice Address - Country:US
Practice Address - Phone:937-427-7540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2009008618363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily