Healthcare Provider Details

I. General information

NPI: 1649712118
Provider Name (Legal Business Name): LAURA KRUGER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2016
Last Update Date: 03/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 COLEMAN DR
ST AUGUSTINE FL
32084-2873
US

IV. Provider business mailing address

5400 S WILLIAMSON BLVD
PORT ORANGE FL
32128-3702
US

V. Phone/Fax

Practice location:
  • Phone: 727-967-1036
  • Fax:
Mailing address:
  • Phone: 609-617-4310
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: