Provider Demographics
NPI:1386629459
Name:PROFFITT, LAURA (RN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:PROFFITT
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11490 SPRINGFIELD PIKE
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3524
Mailing Address - Country:US
Mailing Address - Phone:513-672-3309
Mailing Address - Fax:513-672-3323
Practice Address - Street 1:2139 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2906
Practice Address - Country:US
Practice Address - Phone:513-672-3309
Practice Address - Fax:513-672-3323
Is Sole Proprietor?:No
Enumeration Date:2005-12-13
Last Update Date:2011-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH218047367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000525789OtherANTHEM
KY7100029760Medicaid
OH0193357Medicaid
IN200130890Medicaid
KY617607OtherWELLCARE
311105593 $$$$$$$$$OtherHEALTHNET
KY617607OtherWELLCARE
OHPR8218232Medicare ID - Type Unspecified
311105593 $$$$$$$$$OtherHEALTHNET
KY7100029760Medicaid