Provider Demographics
NPI:1477841799
Name:MANFULL, LAUREN ADDISON (LMP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:ADDISON
Last Name:MANFULL
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 DUGGER ST
Mailing Address - Street 2:
Mailing Address - City:ST MARIES
Mailing Address - State:ID
Mailing Address - Zip Code:83861-2434
Mailing Address - Country:US
Mailing Address - Phone:208-568-0082
Mailing Address - Fax:
Practice Address - Street 1:315 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:ST MARIES
Practice Address - State:ID
Practice Address - Zip Code:83861-2035
Practice Address - Country:US
Practice Address - Phone:208-568-0082
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-20
Last Update Date:2011-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist