Healthcare Provider Details

I. General information

NPI: 1508305541
Provider Name (Legal Business Name): LAURA MEDANIC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/22/2017
Last Update Date: 03/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1013 PENNSYLVANIA AVE # A-C
OTTUMWA IA
52501-2110
US

IV. Provider business mailing address

1001 PENNSYLVANIA AVE
OTTUMWA IA
52501-2186
US

V. Phone/Fax

Practice location:
  • Phone: 641-683-6868
  • Fax: 641-683-6869
Mailing address:
  • Phone: 641-682-7511
  • Fax: 641-684-3199

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number28212530A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberA149465
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: