Provider Demographics
NPI:1487875563
Name:IVERSON, LAUREL JEAN (LMT)
Entity type:Individual
Prefix:MRS
First Name:LAUREL
Middle Name:JEAN
Last Name:IVERSON
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14301 NEON ST NW
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:MN
Mailing Address - Zip Code:55303-5660
Mailing Address - Country:US
Mailing Address - Phone:763-323-8377
Mailing Address - Fax:763-323-9936
Practice Address - Street 1:14301 NEON ST NW
Practice Address - Street 2:
Practice Address - City:RAMSEY
Practice Address - State:MN
Practice Address - Zip Code:55303-5660
Practice Address - Country:US
Practice Address - Phone:763-323-8377
Practice Address - Fax:763-323-9936
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA8639174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist