Provider Demographics
NPI:1396508644
Name:DENNIS, LAUREL ANN (PA)
Entity type:Individual
Prefix:
First Name:LAUREL
Middle Name:ANN
Last Name:DENNIS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 PARK CENTRAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6469
Mailing Address - Country:US
Mailing Address - Phone:803-736-3277
Mailing Address - Fax:803-408-8698
Practice Address - Street 1:145 PARK CENTRAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6469
Practice Address - Country:US
Practice Address - Phone:803-736-3277
Practice Address - Fax:803-408-8698
Is Sole Proprietor?:No
Enumeration Date:2024-01-31
Last Update Date:2024-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC5549363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant