Provider Demographics
NPI:1740276591
Name:HENTHORN, LAURA K (FNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:K
Last Name:HENTHORN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 UNIVERSITY DR E
Mailing Address - Street 2:#100
Mailing Address - City:COLLEGE STATION
Mailing Address - State:TX
Mailing Address - Zip Code:77840-2600
Mailing Address - Country:US
Mailing Address - Phone:979-383-2340
Mailing Address - Fax:979-260-9390
Practice Address - Street 1:3370 S TEXAS AVE
Practice Address - Street 2:SUITE B
Practice Address - City:BRYAN
Practice Address - State:TX
Practice Address - Zip Code:77802-3127
Practice Address - Country:US
Practice Address - Phone:979-595-1700
Practice Address - Fax:979-595-1740
Is Sole Proprietor?:No
Enumeration Date:2005-09-26
Last Update Date:2019-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP110479363LF0000X
TX616612363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1821185299OtherNPI AGENCY
TX154467801Medicaid
TX741715140OtherTAX ID
TX1649265646OtherNPI CLINIC B
TX1649265646OtherNPI CLINIC B