Basic Information
| Provider Information | |||||||||
| NPI: | 1205152626 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GRIFFIN | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | ACNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | SUITE F270 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134410006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6565 FANNIN ST | ||||||||
| Address2: | SUITE F270 | ||||||||
| City: | HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 770302703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7134410006 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2010 | ||||||||
| LastUpdateDate: | 11/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 749154 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
ID Information
| ID | Type | State | Issuer | Description | 215129201 | 05 | TX | MEDICAID | 1205152626 | 01 | TX | BLUE CROSS BLUE SHIELD | OTHER |