Provider Demographics
NPI:1548935653
Name:LAFOLLETTE, MATTHEW R (BSN, RN)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
Last Name:LAFOLLETTE
Suffix:
Gender:M
Credentials:BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1690 SAFFRON DR
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-8619
Mailing Address - Country:US
Mailing Address - Phone:937-707-9551
Mailing Address - Fax:
Practice Address - Street 1:8137 LINDEN LEAF CIR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43235-4618
Practice Address - Country:US
Practice Address - Phone:937-707-9551
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-11
Last Update Date:2021-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.392732163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHRN.392732OtherLICENSES NUMBER