Healthcare Provider Details

I. General information

NPI: 1407990708
Provider Name (Legal Business Name): LAURIE ANN PODESZWA APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 03/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 E STATE ST
ROCKFORD IL
61104-2315
US

IV. Provider business mailing address

PO BOX 1567
ROCKFORD IL
61110-0067
US

V. Phone/Fax

Practice location:
  • Phone: 815-489-4891
  • Fax: 815-967-5312
Mailing address:
  • Phone: 815-489-4891
  • Fax: 815-967-5312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209004715
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: