Provider Demographics
NPI:1407219074
Name:MOYLAN, LAURA T (CLC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:T
Last Name:MOYLAN
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:561 SE MARYDALE TER
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-2217
Mailing Address - Country:US
Mailing Address - Phone:478-361-8399
Mailing Address - Fax:
Practice Address - Street 1:561 SE MARYDALE TER
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34983-2217
Practice Address - Country:US
Practice Address - Phone:478-361-8399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA11875174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN