Provider Demographics
NPI:1245409325
Name:EBERT, LAURIE L
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:L
Last Name:EBERT
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 1:5811 CEDAR LAKE RD S
Mailing Address - Street 2:
Mailing Address - City:ST LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1458
Mailing Address - Country:US
Mailing Address - Phone:952-544-6223
Mailing Address - Fax:952-544-6271
Practice Address - Street 1:5811 CEDAR LAKE RD S
Practice Address - Street 2:
Practice Address - City:ST LOUIS PARK
Practice Address - State:MN
Practice Address - Zip Code:55416-1458
Practice Address - Country:US
Practice Address - Phone:952-544-6223
Practice Address - Fax:952-544-6271
Is Sole Proprietor?:No
Enumeration Date:2008-02-22
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0415899164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse