Provider Demographics
NPI:1326292566
Name:SMALL, LAURA D (NP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:D
Last Name:SMALL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:DEMETRICK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:630 PLANTATION ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01605-2038
Mailing Address - Country:US
Mailing Address - Phone:508-368-3130
Mailing Address - Fax:508-368-3133
Practice Address - Street 1:123 SUMMER ST
Practice Address - Street 2:SUITE 290 N.
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01608-1216
Practice Address - Country:US
Practice Address - Phone:508-368-3130
Practice Address - Fax:508-368-3133
Is Sole Proprietor?:No
Enumeration Date:2008-11-14
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA229942363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner