Provider Demographics
NPI:1053687186
Name:FENTON, LAURIE ANN (NP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:FENTON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E FAIRMOUNT AVE UNIT 7
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:14750-2000
Mailing Address - Country:US
Mailing Address - Phone:716-526-4041
Mailing Address - Fax:
Practice Address - Street 1:1048 PENNSYLVANIA AVE W
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:PA
Practice Address - Zip Code:16365-1838
Practice Address - Country:US
Practice Address - Phone:814-230-9111
Practice Address - Fax:814-313-1075
Is Sole Proprietor?:No
Enumeration Date:2012-03-22
Last Update Date:2022-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY574957-1163W00000X
NYF401506363LP0808X
PASP014720363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse