Provider Demographics
NPI:1689924185
Name:MOODIE, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MOODIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1555 S. LAYTON BLVD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53215
Mailing Address - Country:US
Mailing Address - Phone:414-385-6600
Mailing Address - Fax:
Practice Address - Street 1:1555 S. LAYTON BLVD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53215
Practice Address - Country:US
Practice Address - Phone:414-385-6600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-12
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5029-33363LA2200X
WI171767-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse