Provider Demographics
NPI:1144948001
Name:ROBERTSON, LAUREL J
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:J
Last Name:ROBERTSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREL
Other - Middle Name:J
Other - Last Name:BLASCHIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:30 HYDE AVE STE 109
Mailing Address - Street 2:
Mailing Address - City:VERNON
Mailing Address - State:CT
Mailing Address - Zip Code:06066-4503
Mailing Address - Country:US
Mailing Address - Phone:860-454-0303
Mailing Address - Fax:860-875-4242
Practice Address - Street 1:30 HYDE AVE STE 109
Practice Address - Street 2:
Practice Address - City:VERNON
Practice Address - State:CT
Practice Address - Zip Code:06066-4503
Practice Address - Country:US
Practice Address - Phone:860-454-0303
Practice Address - Fax:860-875-4242
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-17
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT10835363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily