Basic Information
| Provider Information | |||||||||
| NPI: | 1962854323 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOSTER | ||||||||
| FirstName: | LAURIE | ||||||||
| MiddleName: | |||||||||
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| Credential: | AGPCNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 23457 | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392253457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012003631 | ||||||||
| FaxNumber: | 6012000166 | ||||||||
| Practice Location | |||||||||
| Address1: | 969 LAKELAND DR | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392164606 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6012003631 | ||||||||
| FaxNumber: | 6012000166 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2016 | ||||||||
| LastUpdateDate: | 07/20/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | R901651 | MS | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 363L00000X | 901651 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 00529008 | 05 | MS | MEDICAID | 542137YKHV | 01 | MS | MEDICARE | OTHER | P01786049 | 01 | MS | RAILROAD MEDICARE | OTHER |