Provider Demographics
NPI:1861744773
Name:WEATHERFORD, LAURA MARIE (APN, FNP-BC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:WEATHERFORD
Suffix:
Gender:F
Credentials:APN, FNP-BC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:CARLISLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1100 MEDICAL DR STE C
Mailing Address - Street 2:
Mailing Address - City:BLYTHEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72315-2437
Mailing Address - Country:US
Mailing Address - Phone:870-824-2809
Mailing Address - Fax:870-762-0731
Practice Address - Street 1:1100 MEDICAL DR STE C
Practice Address - Street 2:
Practice Address - City:BLYTHEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72315-2437
Practice Address - Country:US
Practice Address - Phone:870-824-2809
Practice Address - Fax:870-762-0731
Is Sole Proprietor?:No
Enumeration Date:2012-10-03
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARATP-000470363LF0000X
ARA003761208VP0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0000XAllopathic & Osteopathic PhysiciansPain MedicinePain Medicine
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily