Provider Demographics
NPI:1962625921
Name:FENDERSON, LAURIE ELIZABETH (CPNP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:ELIZABETH
Last Name:FENDERSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8505 SKYHILLS DR
Mailing Address - Street 2:
Mailing Address - City:ANCHORAGE
Mailing Address - State:AK
Mailing Address - Zip Code:99502-3993
Mailing Address - Country:US
Mailing Address - Phone:512-800-0391
Mailing Address - Fax:
Practice Address - Street 1:ALASKA NATIVE MEDICAL CENTER
Practice Address - Street 2:4315 DIPLOMACY DRIVE
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99508
Practice Address - Country:US
Practice Address - Phone:907-729-1070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0050-00974208000000X
TX681462363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX287667401Medicaid
NC2592552Medicare ID - Type UnspecifiedMEDICARE
TX287667401Medicaid