Provider Demographics
NPI:1427250653
Name:LABORCE, IMELDA BOLANO (LPN)
Entity type:Individual
Prefix:MS
First Name:IMELDA
Middle Name:BOLANO
Last Name:LABORCE
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 1:1677 EARL ST
Mailing Address - Street 2:
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-5533
Mailing Address - Country:US
Mailing Address - Phone:908-686-8782
Mailing Address - Fax:908-687-4198
Practice Address - Street 1:1677 EARL ST
Practice Address - Street 2:
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-5533
Practice Address - Country:US
Practice Address - Phone:908-686-8782
Practice Address - Fax:908-687-4198
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY205105164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01817647Medicaid