Provider Demographics
NPI:1063735850
Name:BOLANDER, LAURA LYNN (MS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LYNN
Last Name:BOLANDER
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:597 THIRD AVENUE
Mailing Address - Street 2:CAPITAL DISTRICT BEGINNINGS
Mailing Address - City:TROY
Mailing Address - State:NY
Mailing Address - Zip Code:12182
Mailing Address - Country:US
Mailing Address - Phone:518-233-0544
Mailing Address - Fax:
Practice Address - Street 1:597 THIRD AVENUE
Practice Address - Street 2:CAPITAL DISTRICT BEGINNINGS
Practice Address - City:TROY
Practice Address - State:NY
Practice Address - Zip Code:12182
Practice Address - Country:US
Practice Address - Phone:518-233-0544
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-08
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY369839091390200000X
NY370021091390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program