Healthcare Provider Details

I. General information

NPI: 1154152619
Provider Name (Legal Business Name): LAURA FENTON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/08/2024
Last Update Date: 08/08/2024
Certification Date: 08/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 PARKVIEW AVE APT 1
BRONX NY
10461-5014
US

IV. Provider business mailing address

31023 COUNTY ROAD 435
SORRENTO FL
32776-7521
US

V. Phone/Fax

Practice location:
  • Phone: 817-791-7131
  • Fax:
Mailing address:
  • Phone: 817-791-7131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number9340289
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code163WI0500X
TaxonomyInfusion Therapy Registered Nurse
License Number753676
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: