Basic Information
| Provider Information | |||||||||
| NPI: | 1972944924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FELLER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | LEE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LINZEY | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | LEE | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 4699 | ||||||||
| Address2: | |||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479034699 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654492732 | ||||||||
| FaxNumber: | 7654491196 | ||||||||
| Practice Location | |||||||||
| Address1: | 1345 UNITY PL | ||||||||
| Address2: | SUITE 345 | ||||||||
| City: | LAFAYETTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 479055760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7654465111 | ||||||||
| FaxNumber: | 7654465165 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2013 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 71004471A | IN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 201199820 | 05 | IN | MEDICAID | 000000835730 | 01 | IN | ANTHEM PROVIDER NUMBER | OTHER |