Basic Information
| Provider Information | |||||||||
| NPI: | 1477718419 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BURNSIDE-MCELLIGOTT | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MCELLIGOTT | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | JEAN | ||||||||
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| OtherCredential: | RN, FNP | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1890 WAITE ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974591229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Practice Location | |||||||||
| Address1: | 1890 WAITE ST | ||||||||
| Address2: | STE 1 | ||||||||
| City: | NORTH BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974591229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417566232 | ||||||||
| FaxNumber: | 5417566234 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2008 | ||||||||
| LastUpdateDate: | 06/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 081046951RN | OR | N | Nursing Service Providers | Registered Nurse | 363LF0000X | 200850064NP FNP-PP | OR | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 213342 | 05 | OR | MEDICAID | 500617181 | 05 | OR | MEDICAID | R163722 | 01 | MEDICARE PTAN | OTHER |