Provider Demographics
NPI:1790046803
Name:LAURA, VIVIANNE REGINA
Entity Type:Individual
Prefix:MS
First Name:VIVIANNE
Middle Name:REGINA
Last Name:LAURA
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 1:14 BAKER ST
Mailing Address - Street 2:APT. D
Mailing Address - City:WEST BABYLON
Mailing Address - State:NY
Mailing Address - Zip Code:11704-8035
Mailing Address - Country:US
Mailing Address - Phone:917-361-2713
Mailing Address - Fax:
Practice Address - Street 1:14 BAKER ST
Practice Address - Street 2:APT. D
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-8035
Practice Address - Country:US
Practice Address - Phone:917-361-2713
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist