Provider Demographics
NPI:1508154873
Name:BLODGETT FERNANDEZ, LAURA NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:NICOLE
Last Name:BLODGETT FERNANDEZ
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15426 SOUTHERN MARTIN ST
Mailing Address - Street 2:
Mailing Address - City:WINTER GARDEN
Mailing Address - State:FL
Mailing Address - Zip Code:34787-4899
Mailing Address - Country:US
Mailing Address - Phone:716-465-4391
Mailing Address - Fax:
Practice Address - Street 1:1155 WINTER GARDEN VINELAND RD STE 102
Practice Address - Street 2:
Practice Address - City:WINTER GARDEN
Practice Address - State:FL
Practice Address - Zip Code:34787-4375
Practice Address - Country:US
Practice Address - Phone:407-656-3755
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-20
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007695152W00000X
FL6347152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist