Provider Demographics
NPI:1750044194
Name:MCINTOSH, LAURA (AGPCNP - BC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MCINTOSH
Suffix:
Gender:F
Credentials:AGPCNP - BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 S JEFFERSON ST APT 409B
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-3819
Mailing Address - Country:US
Mailing Address - Phone:630-363-0529
Mailing Address - Fax:
Practice Address - Street 1:1276 N CLYBOURN AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60610-2003
Practice Address - Country:US
Practice Address - Phone:312-337-1073
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-21
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024224363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209024224Medicaid