Provider Demographics
NPI:1093289902
Name:GRESHAM, LAURYN ELIZABETH
Entity Type:Individual
Prefix:MS
First Name:LAURYN
Middle Name:ELIZABETH
Last Name:GRESHAM
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 1:34697 ROAD 221 WISHON CA 93669
Mailing Address - Street 2:P.O. BOX 852
Mailing Address - City:NORTH FORK CA
Mailing Address - State:CALIFORNIA
Mailing Address - Zip Code:93643
Mailing Address - Country:UM
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6323 N FRESNO ST STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93710-5282
Practice Address - Country:US
Practice Address - Phone:559-439-2307
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-14
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA91009126800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes126800000XDental ProvidersDental Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD8733126OtherNON MEDICARE
CAD8733126OtherSELF