Provider Demographics
NPI:1295925931
Name:ANGER, LAURIE A (NP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
Last Name:ANGER
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 1:1301 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-2122
Mailing Address - Country:US
Mailing Address - Phone:817-820-4906
Mailing Address - Fax:817-250-5441
Practice Address - Street 1:1301 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2122
Practice Address - Country:US
Practice Address - Phone:817-820-4906
Practice Address - Fax:817-250-5441
Is Sole Proprietor?:No
Enumeration Date:2007-07-30
Last Update Date:2015-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704156640363LP0808X
TX558065363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI38-2146751OtherTAX ID NUMBER
TX380237YKPWMedicare PIN