MEDICARE: LAURA K. HENTHORN FNP

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	363LF0000X	Family Nurse Practitioner	AP110479	TX
2	363LA2200X	Adult Health Nurse Practitioner	616612	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1821185299	OTHER	TX	NPI AGENCY
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	741715140	OTHER	TX	TAX ID
4	1649265646	OTHER	TX	NPI CLINIC B

General Provider Information

NPI Number	:	1740276591
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA K. HENTHORN FNP

Provider Business Mailing Address
First Line	:	1500 UNIVERSITY DR E
Second Line	:	#100
City	:	COLLEGE STATION
State	:	TX
Zip	:	77840-2600
Country	:	US
Telephone Number	:	979-383-2340
Fax Number	:	979-260-9390

Provider Business Practice Location Address
First Line	:	3370 S TEXAS AVE
Second Line	:	SUITE B
City	:	BRYAN
State	:	TX
Zip	:	77802-3127
Country	:	US
Telephone Number	:	979-595-1700
Fax Number	:	979-595-1740

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

Provider Enumeration Date	:	09/26/2005
Last Update Date	:	12/27/2019

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