Healthcare Provider Details

I. General information

NPI: 1457455776
Provider Name (Legal Business Name): LAURENCE LEE TRAIL NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1126 HORNELL DR
SILVER SPRING MD
20905-3770
US

IV. Provider business mailing address

1126 HORNELL DRIVE
SILVER SPRING MD
20905-3770
US

V. Phone/Fax

Practice location:
  • Phone: 301-421-9115
  • Fax: 202-745-2283
Mailing address:
  • Phone: 301-421-9115
  • Fax: 202-745-2283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberR083369
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: