Healthcare Provider Details

I. General information

NPI: 1346733847
Provider Name (Legal Business Name): LAURIE RYAN KOTLOWSKI LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LAURIE SUE RYAN LPN

II. Dates (important events)

Enumeration Date: 06/08/2018
Last Update Date: 09/12/2022
Certification Date: 09/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

404 OAKDALE DR
NORTH TONAWANDA NY
14120-2450
US

IV. Provider business mailing address

404 OAKDALE DR.
NORTH TONAWANDA NY
14120-2450
US

V. Phone/Fax

Practice location:
  • Phone: 716-828-5125
  • Fax:
Mailing address:
  • Phone: 716-828-5125
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number332039
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: