Provider Demographics
NPI:1619412392
Name:MUCHMORE, LAURA DIANE (RN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:DIANE
Last Name:MUCHMORE
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 1:11 ROME DOME CT
Mailing Address - Street 2:
Mailing Address - City:STAFFORD
Mailing Address - State:VA
Mailing Address - Zip Code:22556-6666
Mailing Address - Country:US
Mailing Address - Phone:813-390-5915
Mailing Address - Fax:540-737-5698
Practice Address - Street 1:11 ROME DOME CT
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22556-6666
Practice Address - Country:US
Practice Address - Phone:813-390-5915
Practice Address - Fax:540-737-5698
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001230560163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse