Provider Demographics
NPI:1336265313
Name:O'DONNELL, LAURA M (NP)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MRS
Other - First Name:LAURA
Other - Middle Name:M
Other - Last Name:MOYNAHAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 POMEROY MEADOW RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:MA
Mailing Address - Zip Code:01073-9449
Mailing Address - Country:US
Mailing Address - Phone:413-527-9103
Mailing Address - Fax:
Practice Address - Street 1:575 BEECH ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-2223
Practice Address - Country:US
Practice Address - Phone:413-534-2543
Practice Address - Fax:413-534-2655
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA191796363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MANP2659OtherBLUE CROSS
P13511Medicare UPIN
MANP265901Medicare PIN