Provider Demographics
NPI:1770007700
Name:DILL, LAURA J (APRN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:J
Last Name:DILL
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:905 HERITAGE COVE ROW
Mailing Address - Street 2:
Mailing Address - City:REDFIELD
Mailing Address - State:AR
Mailing Address - Zip Code:72132
Mailing Address - Country:US
Mailing Address - Phone:870-718-0287
Mailing Address - Fax:
Practice Address - Street 1:2302 COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72034
Practice Address - Country:US
Practice Address - Phone:501-329-3831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2018-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005284207P00000X, 207Q00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR223358758Medicaid