Provider Demographics
NPI:1689929879
Name:DETTORE, LAUREL ANN (DNSC, MS, RN)
Entity Type:Individual
Prefix:DR
First Name:LAUREL
Middle Name:ANN
Last Name:DETTORE
Suffix:
Gender:F
Credentials:DNSC, MS, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6827 STANLEY AVE
Mailing Address - Street 2:
Mailing Address - City:BERWYN
Mailing Address - State:IL
Mailing Address - Zip Code:60402-3287
Mailing Address - Country:US
Mailing Address - Phone:708-795-1520
Mailing Address - Fax:708-795-1543
Practice Address - Street 1:6827 STANLEY AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3287
Practice Address - Country:US
Practice Address - Phone:708-795-1520
Practice Address - Fax:708-795-1543
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2012-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL214132363LC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LC1500XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCommunity Health