Provider Demographics
NPI:1902850902
Name:WILMOTH, LAURIE A (FNP)
Entity Type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:A
Last Name:WILMOTH
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1040 MAIN ST
Mailing Address - Street 2:PO BOX 1360
Mailing Address - City:DANVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24541-1816
Mailing Address - Country:US
Mailing Address - Phone:434-792-1433
Mailing Address - Fax:434-797-2807
Practice Address - Street 1:1040 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:VA
Practice Address - Zip Code:24541-1816
Practice Address - Country:US
Practice Address - Phone:434-792-1433
Practice Address - Fax:434-797-2807
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024055870363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010115477Medicaid
VA00W201D12Medicare PIN
VA010115477Medicaid