Basic Information
| Provider Information | |||||||||
| NPI: | 1427568351 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WIDYASTAMI | ||||||||
| FirstName: | LAURENSIA | ||||||||
| MiddleName: | HERMY | ||||||||
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| Credential: | AGNP-BC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 61A SUSSEX ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941313011 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262321421 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 450 STANYAN ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941171019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156804135 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2017 | ||||||||
| LastUpdateDate: | 10/05/2017 | ||||||||
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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 | 363L00000X | 95007344 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.