Provider Demographics
NPI:1578043568
Name:KHOSRAVI, LAURA SOLEDAD
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:SOLEDAD
Last Name:KHOSRAVI
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:SOLEDAD
Other - Last Name:GARCIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:306 REDBUD TRCE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78245-2988
Mailing Address - Country:US
Mailing Address - Phone:210-620-8086
Mailing Address - Fax:
Practice Address - Street 1:8700 CROWNHILL BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78209-1128
Practice Address - Country:US
Practice Address - Phone:210-824-5530
Practice Address - Fax:210-824-5323
Is Sole Proprietor?:No
Enumeration Date:2018-08-18
Last Update Date:2018-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX309821164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse