Provider Demographics
NPI:1588915367
Name:ZELLER, LAURA ANNE (APRN, FNP-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANNE
Last Name:ZELLER
Suffix:
Gender:F
Credentials:APRN, FNP-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANNE
Other - Last Name:WORTHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:PO BOX 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4123 DUTCHMAN'S LANE
Practice Address - Street 2:SUITE 301
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4721
Practice Address - Country:US
Practice Address - Phone:502-896-2500
Practice Address - Fax:502-896-2527
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2016-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007675363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100220390Medicaid
KY000000910038OtherANTHEM-KCNS
KY169760OtherSIHO-KCNS
KY50085874OtherPASSPORT - KCNS
KY7100220390Medicaid