Basic Information
| Provider Information | |||||||||
| NPI: | 1871883066 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TULLY | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | JILL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WHITE | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | JILL | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3170 KETTERING BLVD | ||||||||
| Address2: | BUILDING B, 3RD FLOOR | ||||||||
| City: | MORAINE | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454391924 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9379913188 | ||||||||
| FaxNumber: | 9372239811 | ||||||||
| Practice Location | |||||||||
| Address1: | 31 S STANFIELD RD STE 304 | ||||||||
| Address2: | |||||||||
| City: | TROY | ||||||||
| State: | OH | ||||||||
| PostalCode: | 453732334 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9374407872 | ||||||||
| FaxNumber: | 9374407874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2011 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Y00000X | Q7611 | TX | N | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | 35.132034 | OH | Y | Allopathic & Osteopathic Physicians | Otolaryngology | 207Y00000X | GA | N | Allopathic & Osteopathic Physicians | Otolaryngology |
No ID Information.