Provider Demographics
NPI:1114664703
Name:BALLARD, LAUREN CHANEL
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:CHANEL
Last Name:BALLARD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LAUREN
Other - Middle Name:CHANEL
Other - Last Name:CLARDY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2626 EAST 82ND STREET
Mailing Address - Street 2:SUITE 180
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4503
Mailing Address - Country:US
Mailing Address - Phone:952-814-7400
Mailing Address - Fax:952-853-0966
Practice Address - Street 1:2626 EAST 82ND STREET
Practice Address - Street 2:SUITE 180
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-4503
Practice Address - Country:US
Practice Address - Phone:952-814-7400
Practice Address - Fax:952-853-0966
Is Sole Proprietor?:No
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2462593163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse