Healthcare Provider Details

I. General information

NPI: 1477718419
Provider Name (Legal Business Name): LAURA JEAN BURNSIDE-MCELLIGOTT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURA JEAN MCELLIGOTT RN, FNP

II. Dates (important events)

Enumeration Date: 07/18/2008
Last Update Date: 06/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1890 WAITE ST STE 1
NORTH BEND OR
97459-1229
US

IV. Provider business mailing address

1890 WAITE ST STE 1
NORTH BEND OR
97459-1229
US

V. Phone/Fax

Practice location:
  • Phone: 541-756-6232
  • Fax: 541-756-6234
Mailing address:
  • Phone: 541-756-6232
  • Fax: 541-756-6234

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number081046951RN
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200850064NP FNP-PP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: