Provider Demographics
NPI:1780084442
Name:LAUREL LEE HUMPHREY, M.D., PLLC
Entity type:Organization
Organization Name:LAUREL LEE HUMPHREY, M.D., PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSICA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STANGENWALD
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:817-281-9040
Mailing Address - Street 1:5200 COLLEYVILLE BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5892
Mailing Address - Country:US
Mailing Address - Phone:817-281-9040
Mailing Address - Fax:817-281-4249
Practice Address - Street 1:5200 COLLEYVILLE BLVD STE B
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5892
Practice Address - Country:US
Practice Address - Phone:817-281-9040
Practice Address - Fax:817-281-4249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-01
Last Update Date:2014-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM1773207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty