Provider Demographics
NPI:1124878921
Name:BLY, LAURA PATRICIA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:PATRICIA
Last Name:BLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8449 W ROSS AVE
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85382-7424
Mailing Address - Country:US
Mailing Address - Phone:928-231-2662
Mailing Address - Fax:
Practice Address - Street 1:8449 W ROSS AVE
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-7424
Practice Address - Country:US
Practice Address - Phone:928-231-2662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-25
Last Update Date:2024-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ166696163WG0100X, 163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool
No163WG0100XNursing Service ProvidersRegistered NurseGastroenterology