Provider Demographics
NPI:1588059554
Name:LAUTENBACHER, JENNA R (WHNP)
Entity type:Individual
Prefix:
First Name:JENNA
Middle Name:R
Last Name:LAUTENBACHER
Suffix:
Gender:F
Credentials:WHNP
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:R
Other - Last Name:BAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:WHNP
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:EVMS MEDICAL GROUP
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23501-0936
Mailing Address - Country:US
Mailing Address - Phone:757-446-7900
Mailing Address - Fax:757-446-7464
Practice Address - Street 1:825 FAIRFAX AVE
Practice Address - Street 2:SUITE 310
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23507-1914
Practice Address - Country:US
Practice Address - Phone:757-446-7900
Practice Address - Fax:757-446-7464
Is Sole Proprietor?:No
Enumeration Date:2015-04-06
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172492363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1588059554OtherVIRGINIA PREMIER HEALTH PLAN
VA1588059554OtherUSA MANAGED CARE
VAVVH391AMedicare PIN
VA1588059554Medicaid
VA1588059554OtherCORVEL
VA10150106NOtherOPTIMA HEALTH
NC1588059554Medicaid
VA-010OtherTRICARE/CHAMPUS
VA1588059554OtherMULTIPLAN