Provider Demographics
NPI:1699199521
Name:BOECKNER, LAURA (CRNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BOECKNER
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 1:34 E HEATH ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21230-4840
Mailing Address - Country:US
Mailing Address - Phone:308-631-7455
Mailing Address - Fax:
Practice Address - Street 1:11185 STRATFIELD CT
Practice Address - Street 2:
Practice Address - City:MARRIOTTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21104-1659
Practice Address - Country:US
Practice Address - Phone:410-442-4011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-12
Last Update Date:2021-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR197113363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD806202100Medicaid