Healthcare Provider Details

I. General information

NPI: 1730351271
Provider Name (Legal Business Name): LAURA B DOUGLAS LMP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7101 WEST HOOD PL SUITE 102
KENNEWICK WA
99336
US

IV. Provider business mailing address

7101 WEST HOOD PL SUITE 102
KENNEWICK WA
99336
US

V. Phone/Fax

Practice location:
  • Phone: 509-374-4719
  • Fax: 509-374-3873
Mailing address:
  • Phone: 509-374-4719
  • Fax: 509-374-3873

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberMA00025030
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: