Provider Demographics
NPI:1902261944
Name:FITZGIBBON, LAURIE JEAN (NP-C, CCNS)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:JEAN
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:NP-C, CCNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932100
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0008
Mailing Address - Country:US
Mailing Address - Phone:216-472-2730
Mailing Address - Fax:216-472-2740
Practice Address - Street 1:1330 MERCY DR NW
Practice Address - Street 2:SUITE 418
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2626
Practice Address - Country:US
Practice Address - Phone:330-489-1454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-17
Last Update Date:2016-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.18318-NP363LA2200X
OHCOA.10052-NS364SA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No364SA2100XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0152995Medicaid