Healthcare Provider Details

I. General information

NPI: 1104704964
Provider Name (Legal Business Name): LAURA VIRIDIANA ACOSTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA VIRIDIANA MEZA-VEGA

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3012 BROADWAY AVE
HAYS KS
67601-1916
US

IV. Provider business mailing address

3012 BROADWAY AVE
HAYS KS
67601-1916
US

V. Phone/Fax

Practice location:
  • Phone: 785-301-2250
  • Fax:
Mailing address:
  • Phone: 785-301-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number13145988
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: