Provider Demographics
NPI:1013967652
Name:NALL, LAURA COLLEEN (MD)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:COLLEEN
Last Name:NALL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E MCBEE AVE FL 4
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29601-2842
Mailing Address - Country:US
Mailing Address - Phone:864-522-8603
Mailing Address - Fax:
Practice Address - Street 1:11402 ANDERSON RD
Practice Address - Street 2:SUITE A
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29611-7557
Practice Address - Country:US
Practice Address - Phone:864-631-2799
Practice Address - Fax:864-631-2795
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC17556207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC175562Medicaid
SCG01943Medicare UPIN
SC175562Medicaid
SC1153Medicare PIN