Provider Demographics
NPI:1467413898
Name:CANNISTRA, LAURALYN B (MD)
Entity Type:Individual
Prefix:
First Name:LAURALYN
Middle Name:B
Last Name:CANNISTRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 BEECHWOOD AVENUE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-475-1999
Mailing Address - Fax:401-475-6932
Practice Address - Street 1:131 BEECHWOOD AVENUE
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860
Practice Address - Country:US
Practice Address - Phone:401-475-1999
Practice Address - Fax:401-475-6932
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA75195207RC0000X
RIMD08607207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI007057418OtherMEDICARE PTAN
RI9006817Medicaid
F61386Medicare UPIN
007060917Medicare PIN
RI007057418OtherMEDICARE PTAN
007009197Medicare ID - Type Unspecified