Provider Demographics
NPI:1356360499
Name:GORHAM, LAUREL A (CPNP)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:A
Last Name:GORHAM
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:A
Other - Last Name:HAWKINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2205 W LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98902-2437
Mailing Address - Country:US
Mailing Address - Phone:509-469-6305
Mailing Address - Fax:
Practice Address - Street 1:2205 W LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98902-2437
Practice Address - Country:US
Practice Address - Phone:509-469-6305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201507531NP-PP363LP0200X
WAAP60553305363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2972474/10Medicaid
WA2044559Medicaid
OR500693438Medicaid