Provider Demographics
NPI:1124275862
Name:SEGREST, LAURA LEA (FNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:LEA
Last Name:SEGREST
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 12TH ST
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39301-4158
Mailing Address - Country:US
Mailing Address - Phone:601-703-4366
Mailing Address - Fax:601-703-4064
Practice Address - Street 1:1800 12TH ST
Practice Address - Street 2:
Practice Address - City:MERIDIAN
Practice Address - State:MS
Practice Address - Zip Code:39301-4158
Practice Address - Country:US
Practice Address - Phone:601-703-4366
Practice Address - Fax:601-703-4064
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR684813363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01124399Medicaid