Provider Demographics
NPI:1194867523
Name:DILLARD, LAURA A (LPN)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:A
Last Name:DILLARD
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3229 PINECREST DR
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:OH
Mailing Address - Zip Code:44212-3833
Mailing Address - Country:US
Mailing Address - Phone:440-391-4751
Mailing Address - Fax:
Practice Address - Street 1:3229 PINECREST DR
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:OH
Practice Address - Zip Code:44212-3833
Practice Address - Country:US
Practice Address - Phone:440-391-4751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-13
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN100648164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2610384Medicaid