Provider Demographics
NPI:1033757844
Name:STAMBOLY, LAURA A
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:A
Last Name:STAMBOLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17869 COUNTY ROUTE 59
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:NY
Mailing Address - Zip Code:13634-2031
Mailing Address - Country:US
Mailing Address - Phone:315-520-4593
Mailing Address - Fax:
Practice Address - Street 1:93 PUBLIC SQ
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601-2626
Practice Address - Country:US
Practice Address - Phone:315-520-4593
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-12
Last Update Date:2019-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028244225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty