Provider Demographics
NPI:1447511613
Name:STONBORG, LAURA MARIE
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:MARIE
Last Name:STONBORG
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 1:57 LAKESIDE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:NY
Mailing Address - Zip Code:11755-1801
Mailing Address - Country:US
Mailing Address - Phone:631-404-6018
Mailing Address - Fax:
Practice Address - Street 1:57 LAKESIDE AVE
Practice Address - Street 2:
Practice Address - City:LAKE GROVE
Practice Address - State:NY
Practice Address - Zip Code:11755-1801
Practice Address - Country:US
Practice Address - Phone:631-404-6018
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-05
Last Update Date:2012-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist