Basic Information
| Provider Information | |||||||||
| NPI: | 1255593570 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WELLS-SPICER | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
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| NameSuffix: | |||||||||
| Credential: | N.P. | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | WELLS | ||||||||
| OtherFirstName: | LAURA | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1425 PORTLAND AVE | ||||||||
| Address2: | BOX 287 | ||||||||
| City: | ROCHESTER | ||||||||
| State: | NY | ||||||||
| PostalCode: | 146213001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5859225067 | ||||||||
| FaxNumber: | 5859222908 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 DRIVING PARK AVE | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | NY | ||||||||
| PostalCode: | 145131057 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3153592123 | ||||||||
| FaxNumber: | 3153592167 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 05/06/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 301159 | NY | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 03007063-NWK | 05 | NY | MEDICAID | 03490622 | 05 | NY | MEDICAID | 01131126-RGH | 05 | NY | MEDICAID |