Healthcare Provider Details

I. General information

NPI: 1154677466
Provider Name (Legal Business Name): MRS. LAURA GUDDEMI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/24/2012
Last Update Date: 07/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

196 COUNTY ROUTE 1
WARWICK NY
10990-2411
US

IV. Provider business mailing address

196 COUNTY ROUTE 1
WARWICK NY
10990-2411
US

V. Phone/Fax

Practice location:
  • Phone: 845-986-6985
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: