Healthcare Provider Details

I. General information

NPI: 1316125024
Provider Name (Legal Business Name): LAURA ASHLEY ERMENC M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2008
Last Update Date: 09/25/2025
Certification Date: 09/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

616 W FOREST AVE
JACKSON TN
38301-3902
US

IV. Provider business mailing address

PO BOX 400
JACKSON TN
38302-0400
US

V. Phone/Fax

Practice location:
  • Phone: 731-541-7070
  • Fax: 731-541-7075
Mailing address:
  • Phone: 731-423-8697
  • Fax: 731-422-5743

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LC0200X
TaxonomyCritical Care Medicine (Anesthesiology) Physician
License Number101169
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number46400
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number4834-320
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: