Provider Demographics
NPI:1487312781
Name:GAETANO, LAURA KIMBERLY (RN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:KIMBERLY
Last Name:GAETANO
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MS
Other - First Name:LAURA
Other - Middle Name:KIMBERLY
Other - Last Name:WILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2 JOHNNY MERCER BLVD APT 1001
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-3336
Mailing Address - Country:US
Mailing Address - Phone:843-302-1656
Mailing Address - Fax:
Practice Address - Street 1:2 JOHNNY MERCER BLVD APT 1001
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-3336
Practice Address - Country:US
Practice Address - Phone:843-302-1656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-03
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA242611163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA242611OtherREGISTERED NURSE