Provider Demographics
NPI:1326863614
Name:ACEVEDO, LAURA (LPN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:ACEVEDO
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 REVILO AVE
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967-1713
Mailing Address - Country:US
Mailing Address - Phone:631-603-2078
Mailing Address - Fax:
Practice Address - Street 1:2 CORACI BLVD STE 15
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-4833
Practice Address - Country:US
Practice Address - Phone:631-315-2320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-20
Last Update Date:2024-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY259910164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse