Provider Demographics
NPI:1912255159
Name:FUNK, LAURA KATHLEEN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:KATHLEEN
Last Name:FUNK
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 1:110 N LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:WENONAH
Mailing Address - State:NJ
Mailing Address - Zip Code:08090-1732
Mailing Address - Country:US
Mailing Address - Phone:856-415-1328
Mailing Address - Fax:
Practice Address - Street 1:110 NORTH LINCOLN AVENUE
Practice Address - Street 2:
Practice Address - City:WENONAH
Practice Address - State:NJ
Practice Address - Zip Code:08090-1732
Practice Address - Country:US
Practice Address - Phone:856-415-1328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-20
Last Update Date:2012-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA00743300225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist