Provider Demographics
NPI:1275164493
Name:STOVER, LAURIE WIDERMAN
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:WIDERMAN
Last Name:STOVER
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 1:140 E MIDDLE ST
Mailing Address - Street 2:
Mailing Address - City:GETTYSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17325-1938
Mailing Address - Country:US
Mailing Address - Phone:443-791-1562
Mailing Address - Fax:
Practice Address - Street 1:909 FAIRFIELD RD
Practice Address - Street 2:
Practice Address - City:GETTYSBURG
Practice Address - State:PA
Practice Address - Zip Code:17325-7244
Practice Address - Country:US
Practice Address - Phone:717-334-9171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-27
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer