Provider Demographics
NPI:1063644524
Name:MIKKELSEN, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:MIKKELSEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 DANO CIR
Mailing Address - Street 2:APT 2
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-4606
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:820 ROY ST
Practice Address - Street 2:
Practice Address - City:ORTONVILLE
Practice Address - State:MN
Practice Address - Zip Code:56278-1138
Practice Address - Country:US
Practice Address - Phone:320-839-4271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-18
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8374225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist