Basic Information
| Provider Information | |||||||||
| NPI: | 1083741615 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STAFFORD | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | AT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4403 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373953920 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4403 FAR HILLS AVE | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454292405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9373953920 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2007 | ||||||||
| LastUpdateDate: | 01/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2255A2300X | AT001609 | OH | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Specialist/Technologist | Athletic Trainer |
No ID Information.