MEDICARE: LAURA LAVINIA CARDWELL DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP60758521	WA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	AP11094	AZ

General Provider Information

NPI Number	:	1417488347
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA LAVINIA CARDWELL DNP

Provider Business Mailing Address
First Line	:	809 HANCOCK RD STE 1
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-5078
Country	:	US
Telephone Number	:	928-763-7111
Fax Number	:	928-763-7172

Provider Business Practice Location Address
First Line	:	809 HANCOCK RD STE 1
Second Line	:
City	:	BULLHEAD CITY
State	:	AZ
Zip	:	86442-5078
Country	:	US
Telephone Number	:	928-763-7111
Fax Number	:	928-763-7172

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/22/2017
Last Update Date	:	09/24/2020

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