Basic Information
| Provider Information | |||||||||
| NPI: | 1346622594 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REED | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RISNER | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 107 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377622154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237848492 | ||||||||
| FaxNumber: | 4237848358 | ||||||||
| Practice Location | |||||||||
| Address1: | 402 CUMBERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407691238 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065492656 | ||||||||
| FaxNumber: | 6065492855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2015 | ||||||||
| LastUpdateDate: | 05/10/2022 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 3573 | TN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 2301 | KY | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | IN | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | 3573 | 01 | TN | STATE LICENSE | OTHER | 2301 | 01 | KY | STATE LICENSE | OTHER | Q038194 | 05 | TN | MEDICAID | 7100469080 | 05 | KY | MEDICAID |