Healthcare Provider Details

I. General information

NPI: 1467742130
Provider Name (Legal Business Name): MS. LAURA LEE DAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/14/2011
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4800 PEQUASH AVE
CUTCHOGUE NY
11935-2261
US

IV. Provider business mailing address

4800 PEQUASH AVE
CUTCHOGUE NY
11935-2261
US

V. Phone/Fax

Practice location:
  • Phone: 631-413-8424
  • Fax:
Mailing address:
  • Phone: 631-413-8424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number642631
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number205473-1
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number0002065898
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: