Provider Demographics
NPI:1487872826
Name:DESOUZA, LAURIE J (ARNP)
Entity type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:DESOUZA
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 62707
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33906-2707
Mailing Address - Country:US
Mailing Address - Phone:239-931-3440
Mailing Address - Fax:239-931-3458
Practice Address - Street 1:13813 METRO PKWY
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912-4343
Practice Address - Country:US
Practice Address - Phone:239-936-1343
Practice Address - Fax:239-936-8507
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2016-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP1352572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009264900Medicaid
FLY8493OtherFLORIDA BLUE
FL009264900Medicaid