Provider Demographics
NPI:1831188051
Name:BERTHOLD, LAURIE (CPNP)
Entity type:Individual
Prefix:MS
First Name:LAURIE
Middle Name:
Last Name:BERTHOLD
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:BERTHOLD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2651 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93622
Mailing Address - Country:US
Mailing Address - Phone:559-898-6140
Mailing Address - Fax:559-898-6236
Practice Address - Street 1:2651 HIGHLAND AVE
Practice Address - Street 2:KAISER PERMANENTE DEPT OF PEDIATRICS
Practice Address - City:SELMA
Practice Address - State:CA
Practice Address - Zip Code:93662-3392
Practice Address - Country:US
Practice Address - Phone:559-898-6140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-20
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA321100363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP17708Medicare UPIN
CAZZZ19198ZMedicare ID - Type Unspecified