Provider Demographics
NPI:1154690980
Name:LAIRD, KATHERINE (NP)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:LAIRD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4550 MEMORIAL DR
Mailing Address - Street 2:STE. 340
Mailing Address - City:BELLEVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62226-5372
Mailing Address - Country:US
Mailing Address - Phone:618-257-6200
Mailing Address - Fax:618-257-6679
Practice Address - Street 1:20 N WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:DU QUOIN
Practice Address - State:IL
Practice Address - Zip Code:62832-1429
Practice Address - Country:US
Practice Address - Phone:618-542-2129
Practice Address - Fax:618-542-2903
Is Sole Proprietor?:No
Enumeration Date:2011-12-22
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011037562363LA2100X
IL209009247363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$01Medicaid
ILIL3374061Medicare PIN