Provider Demographics
NPI:1477328516
Name:LAVAQUE, SARAH
Entity Type:Individual
Prefix:
First Name:SARAH
Middle Name:
Last Name:LAVAQUE
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 1:428 LEEWARD TRL
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55129-9463
Mailing Address - Country:US
Mailing Address - Phone:651-233-0895
Mailing Address - Fax:
Practice Address - Street 1:1579 HAMLINE AVE N
Practice Address - Street 2:
Practice Address - City:FALCON HEIGHTS
Practice Address - State:MN
Practice Address - Zip Code:55108-2107
Practice Address - Country:US
Practice Address - Phone:651-227-6865
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-20
Last Update Date:2023-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2060171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist