Provider Demographics
NPI:1487946471
Name:TODD, LAURIE NICOLE (PA)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:NICOLE
Last Name:TODD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:NICOLE
Other - Last Name:ELMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3330 NW 56TH ST
Mailing Address - Street 2:STE 206
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73112-4426
Mailing Address - Country:US
Mailing Address - Phone:405-945-4710
Mailing Address - Fax:405-562-9242
Practice Address - Street 1:3330 NW 56TH ST STE 206
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-4426
Practice Address - Country:US
Practice Address - Phone:405-945-4710
Practice Address - Fax:405-562-9242
Is Sole Proprietor?:No
Enumeration Date:2011-05-09
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056098363A00000X
OK2016363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200333010AMedicaid