Provider Demographics
NPI:1689929994
Name:PERNELLI, LAURA ASHLEY (APA-C)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ASHLEY
Last Name:PERNELLI
Suffix:
Gender:F
Credentials:APA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1880 ANASAZI CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-3487
Mailing Address - Country:US
Mailing Address - Phone:717-360-3268
Mailing Address - Fax:
Practice Address - Street 1:3920 BARKELEY AVE
Practice Address - Street 2:
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:097-524-2047
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-24
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0004807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant