Healthcare Provider Details

I. General information

NPI: 1326047358
Provider Name (Legal Business Name): LAURA CATHERINE FORD CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52375 N MAIN ST
MATTAWAN MI
49071-9332
US

IV. Provider business mailing address

52375 N MAIN ST
MATTAWAN MI
49071-9332
US

V. Phone/Fax

Practice location:
  • Phone: 269-668-3348
  • Fax: 269-668-7702
Mailing address:
  • Phone: 269-668-3348
  • Fax: 269-668-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704134722
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number4704134722
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: