Provider Demographics
NPI:1053896522
Name:LAINE, JENNIFER (MSN, RN, FNP-C)
Entity type:Individual
Prefix:MRS
First Name:JENNIFER
Middle Name:
Last Name:LAINE
Suffix:
Gender:F
Credentials:MSN, RN, FNP-C
Other - Prefix:
Other - First Name:JENNA
Other - Middle Name:
Other - Last Name:LAINE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:208 W BEN WHITE BLVD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-7126
Mailing Address - Country:US
Mailing Address - Phone:512-861-8060
Mailing Address - Fax:
Practice Address - Street 1:208 W BEN WHITE BLVD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704
Practice Address - Country:US
Practice Address - Phone:512-861-8060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-01
Last Update Date:2018-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138746363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner