Provider Demographics
NPI:1902278419
Name:FONVILLE, LAURA
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:
Last Name:FONVILLE
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 1:108 SEASIDE AVE
Mailing Address - Street 2:
Mailing Address - City:EGG HARBOR TOWNSHIP
Mailing Address - State:NJ
Mailing Address - Zip Code:08234-7302
Mailing Address - Country:US
Mailing Address - Phone:609-892-2201
Mailing Address - Fax:609-927-7466
Practice Address - Street 1:108 SEASIDE AVE
Practice Address - Street 2:
Practice Address - City:EGG HARBOR TOWNSHIP
Practice Address - State:NJ
Practice Address - Zip Code:08234-7302
Practice Address - Country:US
Practice Address - Phone:609-892-2201
Practice Address - Fax:609-927-7466
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-22
Last Update Date:2015-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ253Z00000X253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care