Provider Demographics
NPI:1124746516
Name:CARRASQUILLO, LAURALYNN (SPECIALIST)
Entity type:Individual
Prefix:
First Name:LAURALYNN
Middle Name:
Last Name:CARRASQUILLO
Suffix:
Gender:F
Credentials:SPECIALIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7767 NW GREENBANK CIR
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34987-3040
Mailing Address - Country:US
Mailing Address - Phone:786-586-8155
Mailing Address - Fax:
Practice Address - Street 1:250 NW PEACOCK BLVD STE 2
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-2205
Practice Address - Country:US
Practice Address - Phone:786-586-8155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL02125151744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management