Provider Demographics
NPI:1689707663
Name:EDWARDS, LAURA
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:EDWARDS
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 1:5 FARNHAM PL
Mailing Address - Street 2:
Mailing Address - City:PORT JEFFERSON STATION
Mailing Address - State:NY
Mailing Address - Zip Code:11776-3412
Mailing Address - Country:US
Mailing Address - Phone:631-331-5016
Mailing Address - Fax:
Practice Address - Street 1:5 FARNHAM PL
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON STATION
Practice Address - State:NY
Practice Address - Zip Code:11776-3412
Practice Address - Country:US
Practice Address - Phone:631-331-5016
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-13
Last Update Date:2007-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist