MEDICARE: LAURALYNN CARRASQUILLO SPECIALIST

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1744P3200X	Prosthetics Case Management	CL0212515	FL

General Provider Information

NPI Number	:	1124746516
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURALYNN CARRASQUILLO SPECIALIST

Provider Business Mailing Address
First Line	:	7767 NW GREENBANK CIR
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34987-3040
Country	:	US
Telephone Number	:	786-586-8155
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 NW PEACOCK BLVD STE 2
Second Line	:
City	:	PORT ST LUCIE
State	:	FL
Zip	:	34986-2205
Country	:	US
Telephone Number	:	786-586-8155
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/22/2022
Last Update Date	:	08/22/2022

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Directions to “ LAURALYNN CARRASQUILLO SPECIALIST” Practice Location

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