Provider Demographics
NPI:1144461757
Name:WELTY, LAUREL LYNN (APN)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:LYNN
Last Name:WELTY
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:722 N 10TH ST
Mailing Address - Street 2:
Mailing Address - City:MONMOUTH
Mailing Address - State:IL
Mailing Address - Zip Code:61462-1430
Mailing Address - Country:US
Mailing Address - Phone:317-473-3587
Mailing Address - Fax:
Practice Address - Street 1:722 N 10TH ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1430
Practice Address - Country:US
Practice Address - Phone:317-473-3587
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-03-11
Last Update Date:2015-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA105881363LF0000X
IN28197693A363LF0000X
TX829265363LF0000X
LA141990-7545363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1144461757Medicaid
IA1144461757OtherWELLMARK
IA511790002Medicare PIN