MEDICARE: MS. LAURIE BOENNING PT, MA

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	225100000X	Physical Therapist	QA04593	NJ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2133806	OTHER	NJ	AETNA

General Provider Information

NPI Number	:	1801842166
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LAURIE BOENNING PT, MA

Provider Business Mailing Address
First Line	:	2417 BRIDGE AVE
Second Line	:
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-4334
Country	:	US
Telephone Number	:	732-701-9320
Fax Number	:	732-701-9321

Provider Business Practice Location Address
First Line	:	2417 BRIDGE AVE
Second Line	:
City	:	POINT PLEASANT BORO
State	:	NJ
Zip	:	08742-4334
Country	:	US
Telephone Number	:	732-701-9320
Fax Number	:	732-701-9321

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

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	03/18/2011

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