Provider Demographics
NPI:1881861573
Name:DEAK, LAURA ANNE (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:DEAK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:EVERETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:574-237-6069
Practice Address - Street 1:615 N MICHIGAN ST
Practice Address - Street 2:1ST FL HOSPITALIST STE
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1033
Practice Address - Country:US
Practice Address - Phone:574-647-3050
Practice Address - Fax:574-647-1094
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006165A363LN0000X, 363LN0000X
MIDEA1-0433-2792363LN0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300011766Medicaid