Healthcare Provider Details

I. General information

NPI: 1669037081
Provider Name (Legal Business Name): LAURA ESESE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3640 BRAMBLEBERRY DR NW
COMSTOCK PARK MI
49321-9796
US

IV. Provider business mailing address

3640 BRAMBLEBERRY DR NW
COMSTOCK PARK MI
49321-9796
US

V. Phone/Fax

Practice location:
  • Phone: 614-570-7322
  • Fax:
Mailing address:
  • Phone: 614-570-7322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number4704277381
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: