Provider Demographics
NPI:1356018899
Name:LUNDBERG, LAURA SUE ELLEN
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:SUE ELLEN
Last Name:LUNDBERG
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 1:878 COMPANY HOUSE RD
Mailing Address - Street 2:
Mailing Address - City:TUNNELTON
Mailing Address - State:WV
Mailing Address - Zip Code:26444-7104
Mailing Address - Country:US
Mailing Address - Phone:304-435-8210
Mailing Address - Fax:
Practice Address - Street 1:878 COMPANY HOUSE RD
Practice Address - Street 2:
Practice Address - City:TUNNELTON
Practice Address - State:WV
Practice Address - Zip Code:26444-7104
Practice Address - Country:US
Practice Address - Phone:304-435-8210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant