Provider Demographics
NPI:1043892094
Name:MANDELL, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MANDELL
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 1:2701 TAMARACK AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH WINDSOR
Mailing Address - State:CT
Mailing Address - Zip Code:06074-5562
Mailing Address - Country:US
Mailing Address - Phone:860-647-8282
Mailing Address - Fax:
Practice Address - Street 1:2701 TAMARACK AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-5562
Practice Address - Country:US
Practice Address - Phone:508-259-6656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-28
Last Update Date:2021-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA134948163WP0200X
CT134948163WP0200X
CT9678363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No163WP0200XNursing Service ProvidersRegistered NursePediatrics