Provider Demographics
NPI:1972718187
Name:LAURA H. BOMAN, CRNP
Entity Type:Organization
Organization Name:LAURA H. BOMAN, CRNP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BOOKKEEPER
Authorized Official - Prefix:
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CHESNUTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-281-6363
Mailing Address - Street 1:PO BOX 201325
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36120-1325
Mailing Address - Country:US
Mailing Address - Phone:334-284-4253
Mailing Address - Fax:
Practice Address - Street 1:2023 NORMANDIE DR
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111-2711
Practice Address - Country:US
Practice Address - Phone:334-284-4253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2007-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201793363LF0000X
AL1-041326363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000969Medicaid
ALB0051506240Medicaid
NC7000969Medicaid
NC2809812Medicare ID - Type Unspecified