Provider Demographics
NPI:1558652446
Name:SEVEREIDE, DEBRA JEAN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DEBRA
Middle Name:JEAN
Last Name:SEVEREIDE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 QUARTER HORSE LN
Mailing Address - Street 2:
Mailing Address - City:CODY
Mailing Address - State:WY
Mailing Address - Zip Code:82414-8204
Mailing Address - Country:US
Mailing Address - Phone:307-899-5754
Mailing Address - Fax:
Practice Address - Street 1:34 QUARTER HORSE LN
Practice Address - Street 2:
Practice Address - City:CODY
Practice Address - State:WY
Practice Address - Zip Code:82414-8204
Practice Address - Country:US
Practice Address - Phone:307-899-5754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-26
Last Update Date:2011-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT3633164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse