Provider Demographics
NPI:1992389241
Name:FENTON, LAURA SULLIVAN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SULLIVAN
Last Name:FENTON
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 1:293 CREEKRIDGE CIR NW
Mailing Address - Street 2:
Mailing Address - City:ACWORTH
Mailing Address - State:GA
Mailing Address - Zip Code:30102-6903
Mailing Address - Country:US
Mailing Address - Phone:229-328-5371
Mailing Address - Fax:
Practice Address - Street 1:2001 PROFESSIONAL PKWY STE 220
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30188-6444
Practice Address - Country:US
Practice Address - Phone:844-543-8437
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2021-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT014284225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist