Provider Demographics
NPI:1790730042
Name:STAUB, LAURIE M (NP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:M
Last Name:STAUB
Suffix:
Gender:F
Credentials:NP
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 658
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30503-0658
Mailing Address - Country:US
Mailing Address - Phone:770-718-1122
Mailing Address - Fax:770-533-4786
Practice Address - Street 1:725 JESSE JEWELL PKWY SE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-3834
Practice Address - Country:US
Practice Address - Phone:770-534-1986
Practice Address - Fax:770-297-5645
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2021-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAR081873363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA500020776OtherRR MEDICARE-GRP # CC4177
GA000706384AMedicaid
GA10053490OtherAMERIGROUP
GA335920OtherWELLCARE
GA000706384AMedicaid
P24273Medicare UPIN