Healthcare Provider Details

I. General information

NPI: 1518351980
Provider Name (Legal Business Name): LAURA ELIZABETH WALAWENDER M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2015
Last Update Date: 02/10/2025
Certification Date: 02/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

IV. Provider business mailing address

305 E JEFFERSON ST
BOISE ID
83712-6231
US

V. Phone/Fax

Practice location:
  • Phone: 208-381-7336
  • Fax: 208-381-7495
Mailing address:
  • Phone: 208-381-7336
  • Fax: 208-381-7495

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number35-131822
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code2080P0204X
TaxonomyPediatric Emergency Medicine (Pediatrics) Physician
License Number35-131822
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number35-131822
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code2080P0210X
TaxonomyPediatric Nephrology Physician
License NumberM-17763
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: