Provider Demographics
NPI:1770629198
Name:GORE, LAURA LEE (CDM)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LEE
Last Name:GORE
Suffix:
Gender:F
Credentials:CDM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 112051
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99511-2051
Mailing Address - Country:US
Mailing Address - Phone:907-770-0377
Mailing Address - Fax:
Practice Address - Street 1:3730 RHONE CIR
Practice Address - Street 2:SUITE 103
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508-5051
Practice Address - Country:US
Practice Address - Phone:907-561-5152
Practice Address - Fax:907-562-2585
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK0026176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKNM0026Medicaid