Provider Demographics
NPI:1316603327
Name:BERGLASS, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BERGLASS
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 1:279 NEW BRITAIN RD
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:CT
Mailing Address - Zip Code:06037-1395
Mailing Address - Country:US
Mailing Address - Phone:860-438-7096
Mailing Address - Fax:
Practice Address - Street 1:279 NEW BRITAIN RD
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:CT
Practice Address - Zip Code:06037-1395
Practice Address - Country:US
Practice Address - Phone:860-438-7096
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-14
Last Update Date:2021-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10222363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner