Provider Demographics
NPI:1104262443
Name:KNISLEY, LAURA A (CNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:A
Last Name:KNISLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 PRESTIGE PL STE 550
Mailing Address - Street 2:
Mailing Address - City:MIAMISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45342-6115
Mailing Address - Country:US
Mailing Address - Phone:937-762-1310
Mailing Address - Fax:
Practice Address - Street 1:2510 COMMONS BLVD STE 160
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-3834
Practice Address - Country:US
Practice Address - Phone:937-425-4010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7571133V00000X
OHRN286015163WL0100X
OHCNP021904363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty