Provider Demographics
NPI:1760594162
Name:THEEKE, LAURIE A (CFNP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:THEEKE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P. O. BOX 897
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26507-0897
Mailing Address - Country:US
Mailing Address - Phone:304-293-7401
Mailing Address - Fax:304-293-6963
Practice Address - Street 1:1 MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:MORGANTONW
Practice Address - State:WV
Practice Address - Zip Code:26506
Practice Address - Country:US
Practice Address - Phone:304-598-6900
Practice Address - Fax:304-598-6914
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV037148363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0166639000Medicaid
WV0166639000Medicaid
WVS09370Medicare UPIN