Healthcare Provider Details

I. General information

NPI: 1962625921
Provider Name (Legal Business Name): LAURIE ELIZABETH FENDERSON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ALASKA NATIVE MEDICAL CENTER 4315 DIPLOMACY DRIVE
ANCHORAGE AK
99508
US

IV. Provider business mailing address

8505 SKYHILLS DR
ANCHORAGE AK
99502-3993
US

V. Phone/Fax

Practice location:
  • Phone: 907-729-1070
  • Fax:
Mailing address:
  • Phone: 512-800-0391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0050-00974
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number681462
License Number StateTX

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier287667401
Identifier TypeMEDICAID
Identifier StateTX
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: