Provider Demographics
NPI:1629567656
Name:BREEDEN, LAURA (LAC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:BREEDEN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3846 LYNDHURST DR APT 301
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX, VA
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:703-655-5442
Mailing Address - Fax:
Practice Address - Street 1:3846 LYNDHURST DR APT 301
Practice Address - Street 2:
Practice Address - City:FAIRFAX, VA
Practice Address - State:VA
Practice Address - Zip Code:22031
Practice Address - Country:US
Practice Address - Phone:703-655-5442
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2018-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121000829171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist