Basic Information
Provider Information | |||||||||
NPI: | 1477804508 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ERICKSON | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | L | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | PNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | MOON | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | L | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 1026 | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462061026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3177776435 | ||||||||
FaxNumber: | 3177776644 | ||||||||
Practice Location | |||||||||
Address1: | 705 RILEY HOSPITAL DR | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462025109 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172748812 | ||||||||
FaxNumber: | 3172740133 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/28/2012 | ||||||||
LastUpdateDate: | 07/13/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | 71004146A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
ID | Type | State | Issuer | Description | 201132180 | 05 | IN |   | MEDICAID |