Healthcare Provider Details

I. General information

NPI: 1447179692
Provider Name (Legal Business Name): LAURA LAKE CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/13/2026
Certification Date: 07/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 4TH AVE SW STE A
REFORM AL
35481-8018
US

IV. Provider business mailing address

108 4TH AVE SW STE A
REFORM AL
35481-8018
US

V. Phone/Fax

Practice location:
  • Phone: 205-375-6251
  • Fax: 205-375-9064
Mailing address:
  • Phone: 205-375-6251
  • Fax: 205-375-9064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number1191389
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number1191389
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: