Provider Demographics
NPI:1720315047
Name:KIELB, LAURA MARIE
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:KIELB
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:PO BOX 789
Mailing Address - Street 2:
Mailing Address - City:LUDLOW
Mailing Address - State:MA
Mailing Address - Zip Code:01056-0789
Mailing Address - Country:US
Mailing Address - Phone:413-509-1000
Mailing Address - Fax:413-509-1003
Practice Address - Street 1:201 CHESTNUT HILL RD
Practice Address - Street 2:
Practice Address - City:STAFFORD SPRINGS
Practice Address - State:CT
Practice Address - Zip Code:06076-4005
Practice Address - Country:US
Practice Address - Phone:860-684-8431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-06
Last Update Date:2010-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA871299146N00000X
CT002332363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No146N00000XEmergency Medical Service ProvidersEmergency Medical Technician, Basic