Basic Information
| Provider Information | |||||||||
| NPI: | 1588822118 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIEFENDORF | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | PATRICIA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SMITH | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | PATRICIA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7021 HARPS MILL RD | ||||||||
| Address2: | STE 100 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276153240 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204855 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 480 RUIN CREEK RD | ||||||||
| Address2: | HENDERSON FAMILY MEDICINE CLINIC | ||||||||
| City: | HENDERSON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275362929 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2524923152 | ||||||||
| FaxNumber: | 2524301928 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 2012-00449 | NC | N | Allopathic & Osteopathic Physicians | Pediatrics | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207R00000X | 2012-00449 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.