Healthcare Provider Details

I. General information

NPI: 1376852467
Provider Name (Legal Business Name): LAURA ANNE COSENZA CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/07/2010
Last Update Date: 11/17/2023
Certification Date: 11/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1162 MONTGOMERY DR
SANTA ROSA CA
95405-4802
US

IV. Provider business mailing address

904 7TH AVE
SEATTLE WA
98104-1132
US

V. Phone/Fax

Practice location:
  • Phone: 707-890-4250
  • Fax:
Mailing address:
  • Phone: 206-860-5572
  • Fax: 206-720-7418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95027884
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number05894-NP
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP60053122
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: