Provider Demographics
NPI:1063829240
Name:MIYAMASU, LAUREN K (NP-C)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:K
Last Name:MIYAMASU
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 OAKLEY AVE
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45419-2352
Mailing Address - Country:US
Mailing Address - Phone:937-623-1240
Mailing Address - Fax:
Practice Address - Street 1:1 WYOMING ST # M4487
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45409-2711
Practice Address - Country:US
Practice Address - Phone:937-208-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-19
Last Update Date:2024-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.16242-NP363LF0000X
OHAPRN.CNP.16242363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0107803Medicaid
OH0107803Medicaid