Provider Demographics
NPI:1962456186
Name:GRAUEL, LAURIE J (MD)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:J
Last Name:GRAUEL
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 VIRGINIA AVE
Mailing Address - Street 2:SUITE 107
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1275 WAMPANOAG TRL
Practice Address - Street 2:SUITE 200
Practice Address - City:RIVERSIDE
Practice Address - State:RI
Practice Address - Zip Code:02915-1217
Practice Address - Country:US
Practice Address - Phone:401-433-9880
Practice Address - Fax:401-433-9838
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2012-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA52717208000000X
RIMD06362208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics