Provider Demographics
NPI:1700577301
Name:VANDERJAGT, LAURIE DANIELLE
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:DANIELLE
Last Name:VANDERJAGT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 YUCCA ST
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87505-5456
Mailing Address - Country:US
Mailing Address - Phone:505-379-4719
Mailing Address - Fax:
Practice Address - Street 1:2100 YUCCA ST
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-5456
Practice Address - Country:US
Practice Address - Phone:505-379-4719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-16
Last Update Date:2023-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM10468528163WS0200X
NMR47242163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool