Provider Demographics
NPI:1629331590
Name:PRISTACH, LAUREL ANNE (MSED)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:ANNE
Last Name:PRISTACH
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:ANNE
Other - Last Name:STALLONE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSED
Mailing Address - Street 1:18 FLORAL RD
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9605
Mailing Address - Country:US
Mailing Address - Phone:631-648-8938
Mailing Address - Fax:
Practice Address - Street 1:18 FLORAL RD
Practice Address - Street 2:
Practice Address - City:ROCKY POINT
Practice Address - State:NY
Practice Address - Zip Code:11778-9605
Practice Address - Country:US
Practice Address - Phone:631-648-8938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-16
Last Update Date:2012-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1730806174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist