Provider Demographics
NPI:1770765331
Name:WILSON, LAURA BETH (LPN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:BETH
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8765 S HILL RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND PATENT
Mailing Address - State:NY
Mailing Address - Zip Code:13354-4050
Mailing Address - Country:US
Mailing Address - Phone:315-827-4902
Mailing Address - Fax:
Practice Address - Street 1:8765 S HILL RD
Practice Address - Street 2:
Practice Address - City:HOLLAND PATENT
Practice Address - State:NY
Practice Address - Zip Code:13354-4050
Practice Address - Country:US
Practice Address - Phone:315-827-4902
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-05
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269733-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02899558Medicaid