Provider Demographics
NPI:1578216818
Name:JENSEN RILEY, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:JENSEN RILEY
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 1:2092 LAKE TAHOE BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:S LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-6429
Mailing Address - Country:US
Mailing Address - Phone:530-600-1960
Mailing Address - Fax:
Practice Address - Street 1:2092 LAKE TAHOE BLVD STE 500
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-6429
Practice Address - Country:US
Practice Address - Phone:530-600-1960
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-27
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV845484363L00000X
CA95019852363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner