Provider Demographics
NPI:1760787881
Name:KOS, LAURA KELLEY (CPNP)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:KELLEY
Last Name:KOS
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:64 OSPREY DR
Mailing Address - Street 2:
Mailing Address - City:GROTON
Mailing Address - State:CT
Mailing Address - Zip Code:06340-3132
Mailing Address - Country:US
Mailing Address - Phone:214-926-8608
Mailing Address - Fax:
Practice Address - Street 1:333 CEDAR ST
Practice Address - Street 2:ROOM WWW305
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3206
Practice Address - Country:US
Practice Address - Phone:203-785-2660
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-20
Last Update Date:2011-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT4194363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics