Provider Demographics
NPI:1619301876
Name:RETZLAFF, LAURIE MAE (RN)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:MAE
Last Name:RETZLAFF
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 1:235 BELMONT AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2805
Mailing Address - Country:US
Mailing Address - Phone:917-202-8621
Mailing Address - Fax:
Practice Address - Street 1:235 BELMONT AVE
Practice Address - Street 2:
Practice Address - City:ELMONT
Practice Address - State:NY
Practice Address - Zip Code:11003-2805
Practice Address - Country:US
Practice Address - Phone:917-202-8621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-23
Last Update Date:2013-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY675363-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY675363-1Medicaid