Healthcare Provider Details

I. General information

NPI: 1801594882
Provider Name (Legal Business Name): NICOLE ANN LAAS FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1923 W GLEN PARK AVE
GRIFFITH IN
46319-3703
US

IV. Provider business mailing address

965 DOE PATH LN
CROWN POINT IN
46307-5051
US

V. Phone/Fax

Practice location:
  • Phone: 219-922-2535
  • Fax: 219-922-5478
Mailing address:
  • Phone: 219-794-5180
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number71013557A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: