Provider Demographics
NPI:1609751403
Name:LAUCK, AJA (FNP-C)
Entity type:Individual
Prefix:
First Name:AJA
Middle Name:
Last Name:LAUCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5236 N VALLE DORADO
Mailing Address - Street 2:
Mailing Address - City:KINGMAN
Mailing Address - State:AZ
Mailing Address - Zip Code:86409-1689
Mailing Address - Country:US
Mailing Address - Phone:928-727-0106
Mailing Address - Fax:
Practice Address - Street 1:5236 N VALLE DORADO
Practice Address - Street 2:
Practice Address - City:KINGMAN
Practice Address - State:AZ
Practice Address - Zip Code:86409-1689
Practice Address - Country:US
Practice Address - Phone:928-727-0106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ281349363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily