Provider Demographics
NPI:1619368982
Name:MYDLOWSKI, LAURA ANN
Entity Type:Individual
Prefix:MISS
First Name:LAURA
Middle Name:ANN
Last Name:MYDLOWSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1605 BRIDLE CREEK CT
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23464-8525
Mailing Address - Country:US
Mailing Address - Phone:757-619-1724
Mailing Address - Fax:
Practice Address - Street 1:1605 BRIDLE CREEK CT
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23464-8525
Practice Address - Country:US
Practice Address - Phone:757-619-1724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-09
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0230017840247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other