Basic Information
| Provider Information | |||||||||
| NPI: | 1548233380 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANKRUM | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | J | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75-5751 KUAKINI HWY STE 203 | ||||||||
| Address2: | |||||||||
| City: | KAILUA KONA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967401753 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083265629 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 75-5751 KUAKINI HWY STE 101A | ||||||||
| Address2: | |||||||||
| City: | KAILUA KONA | ||||||||
| State: | HI | ||||||||
| PostalCode: | 967401705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8083265629 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/10/2006 | ||||||||
| LastUpdateDate: | 02/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 5101014524 | MI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 46621 021 | WI | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | DOS-1552 | HI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 43512500 | 05 | WI | MEDICAID | 4606364 | 05 | MI | MEDICAID | 4606346 | 05 | MI | MEDICAID | 762543 | 05 | HI | MEDICAID |