Provider Demographics
NPI:1700314754
Name:WILLARD, LAURA B (AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:B
Last Name:WILLARD
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 277723
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-7723
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:864-560-4023
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6000
Practice Address - Fax:864-560-4023
Is Sole Proprietor?:No
Enumeration Date:2017-06-02
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC21035363L00000X, 363LA2100X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCSCB2373365OtherMEDICARE PIN
SCNP7068Medicaid
SCSCB2375019OtherMEDICARE PIN
SCSCB2376084OtherMEDICARE PIN
SCSCB237O696OtherMEDICARE PIN