Provider Demographics
NPI:1578029641
Name:LAUDICK, BREANNA L (PA)
Entity Type:Individual
Prefix:
First Name:BREANNA
Middle Name:L
Last Name:LAUDICK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:BREANNA
Other - Middle Name:L
Other - Last Name:HANNA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:45 ST LAWRENCE DR
Mailing Address - Street 2:
Mailing Address - City:TIFFIN
Mailing Address - State:OH
Mailing Address - Zip Code:44883-8310
Mailing Address - Country:US
Mailing Address - Phone:419-455-7480
Mailing Address - Fax:419-455-7482
Practice Address - Street 1:45 ST LAWRENCE DR
Practice Address - Street 2:
Practice Address - City:TIFFIN
Practice Address - State:OH
Practice Address - Zip Code:44883-8310
Practice Address - Country:US
Practice Address - Phone:419-455-7480
Practice Address - Fax:419-455-7482
Is Sole Proprietor?:No
Enumeration Date:2019-02-14
Last Update Date:2023-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.005874RX363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical