Healthcare Provider Details

I. General information

NPI: 1154962249
Provider Name (Legal Business Name): LAURA ANN LASTER APRN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2019
Last Update Date: 10/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3135 190TH ST
LANSING IL
60438-3455
US

IV. Provider business mailing address

3135 190TH ST
LANSING IL
60438-3455
US

V. Phone/Fax

Practice location:
  • Phone: 218-851-5101
  • Fax:
Mailing address:
  • Phone: 218-851-5101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number041446344
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28225021A
License Number StateIN
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209020064
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: