Provider Demographics
NPI:1427224807
Name:PONELLA, LARAINE ANNE (RN)
Entity Type:Individual
Prefix:MISS
First Name:LARAINE
Middle Name:ANNE
Last Name:PONELLA
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:50 MILLAND DR
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-2835
Mailing Address - Country:US
Mailing Address - Phone:631-754-5522
Mailing Address - Fax:
Practice Address - Street 1:50 MILLAND DR
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2835
Practice Address - Country:US
Practice Address - Phone:631-754-5522
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2008-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY381589163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02668495Medicaid