Provider Demographics
NPI:1154152619
Name:FENTON, LAURA (RN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:FENTON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31023 COUNTY ROAD 435
Mailing Address - Street 2:
Mailing Address - City:SORRENTO
Mailing Address - State:FL
Mailing Address - Zip Code:32776-7521
Mailing Address - Country:US
Mailing Address - Phone:817-791-7131
Mailing Address - Fax:
Practice Address - Street 1:1708 PARKVIEW AVE APT 1
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-5014
Practice Address - Country:US
Practice Address - Phone:817-791-7131
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2024-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9340289163WI0500X
NY753676163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy