Provider Demographics
NPI:1083963417
Name:CIVIL, LAURE GABRIELLE (LPN)
Entity Type:Individual
Prefix:
First Name:LAURE
Middle Name:GABRIELLE
Last Name:CIVIL
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37B SEABRING ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:NY
Mailing Address - Zip Code:10977-5132
Mailing Address - Country:US
Mailing Address - Phone:845-290-0921
Mailing Address - Fax:
Practice Address - Street 1:37B SEABRING ST
Practice Address - Street 2:
Practice Address - City:SPRING VALLEY
Practice Address - State:NY
Practice Address - Zip Code:10977-5132
Practice Address - Country:US
Practice Address - Phone:845-290-0921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-30
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY310333-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY1960Medicaid
NY1963Medicare PIN