Healthcare Provider Details

I. General information

NPI: 1497228175
Provider Name (Legal Business Name): LAURA L KORTY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/06/2019
Last Update Date: 01/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

906 PRINCESS DR
WEST LAFAYETTE IN
47906-2040
US

IV. Provider business mailing address

906 PRINCESS DR
WEST LAFAYETTE IN
47906-2040
US

V. Phone/Fax

Practice location:
  • Phone: 765-491-2482
  • Fax:
Mailing address:
  • Phone: 765-491-2482
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number28199730A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code222Q00000X
TaxonomyDevelopmental Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: