Basic Information
| Provider Information | |||||||||
| NPI: | 1093058463 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PURDY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ELLEN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SCHIESS | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | ELLEN | ||||||||
| OtherNamePrefix: | DR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 422235318 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 650 JOEL DR | ||||||||
| Address2: | |||||||||
| City: | FORT CAMPBELL | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707988388 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2013 | ||||||||
| LastUpdateDate: | 09/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A158424 | CA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 69427 | GA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | D86185 | MD | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 56179 | AZ | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 50375 | KY | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 2018-01536 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 35.133756 | OH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 55905 | TN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.