Provider Demographics
NPI:1861595480
Name:WELLER, LAURA A (DC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:WELLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:A
Other - Last Name:WELLER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DC
Mailing Address - Street 1:2090 MLK ST N
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33704
Mailing Address - Country:US
Mailing Address - Phone:727-894-7528
Mailing Address - Fax:727-823-6073
Practice Address - Street 1:2090 MLK ST N
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33704
Practice Address - Country:US
Practice Address - Phone:727-894-7528
Practice Address - Fax:727-823-6073
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH8030111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
53871Medicare ID - Type Unspecified