Provider Demographics
NPI:1376020008
Name:MARCIONETTE, LAURIE ANN (LDO)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:ANN
Last Name:MARCIONETTE
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4359 35TH ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33714-3717
Mailing Address - Country:US
Mailing Address - Phone:727-914-8615
Mailing Address - Fax:727-914-8610
Practice Address - Street 1:13128 CORTEZ BLVD
Practice Address - Street 2:
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-4858
Practice Address - Country:US
Practice Address - Phone:352-597-0410
Practice Address - Fax:352-515-0750
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-25
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLDO2242156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician