Basic Information
| Provider Information | |||||||||
| NPI: | 1962516450 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ANDERSON | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | APRN | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 3755 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 681030755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023542100 | ||||||||
| FaxNumber: | 4023542155 | ||||||||
| Practice Location | |||||||||
| Address1: | 11946 STANDING STONE DR | ||||||||
| Address2: | |||||||||
| City: | GRETNA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 680288094 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4028154500 | ||||||||
| FaxNumber: | 4028154510 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 110811 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LF0000X | 110811 | NE | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 47068731741 | 05 | NE | MEDICAID | 47068731749 | 05 | NE | MEDICAID | 47068731734 | 05 | NE | MEDICAID | 10026450100 | 05 | NE | MEDICAID | 10026450100 | 05 | IA | MEDICAID |