Basic Information
Provider Information | |||||||||
NPI: | 1508000563 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEFEVER | ||||||||
FirstName: | LAURA | ||||||||
MiddleName: | ELISE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DO | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DE LEON | ||||||||
OtherFirstName: | LAURA | ||||||||
OtherMiddleName: | ELISE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DO | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1115 SE 164TH AVE DEPT 358 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986838004 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1660 DELAWARE ST | ||||||||
Address2: |   | ||||||||
City: | LONGVIEW | ||||||||
State: | WA | ||||||||
PostalCode: | 986322310 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604142800 | ||||||||
FaxNumber: | 3604142803 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/21/2009 | ||||||||
LastUpdateDate: | 04/30/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/30/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | OP60389049 | WA | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
ID Information
ID | Type | State | Issuer | Description | 2030040 | 05 | WA |   | MEDICAID | USE NPI | 05 | OR |   | MEDICAID |