Provider Demographics
NPI:1154512382
Name:WYBENGA, LAURIE KRISTEN (FNP NP-C)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:KRISTEN
Last Name:WYBENGA
Suffix:
Gender:F
Credentials:FNP NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7703 FLOYD CURL DR
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-567-2788
Mailing Address - Fax:
Practice Address - Street 1:222 HERLONG AVE S
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1158
Practice Address - Country:US
Practice Address - Phone:803-324-3500
Practice Address - Fax:803-327-8505
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2022-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP127899363LF0000X
SCRX3228363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1237Medicaid
TX346508001Medicaid
TX415355YK00Medicare PIN