Healthcare Provider Details

I. General information

NPI: 1962456186
Provider Name (Legal Business Name): LAURIE J GRAUEL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 WAMPANOAG TRL SUITE 200
RIVERSIDE RI
02915-1217
US

IV. Provider business mailing address

17 VIRGINIA AVE SUITE 107
PROVIDENCE RI
02905-4406
US

V. Phone/Fax

Practice location:
  • Phone: 401-433-9880
  • Fax: 401-433-9838
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number52717
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD06362
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: