Provider Demographics
NPI:1659623247
Name:EVANS, LAURA ANN (NCTM)
Entity Type:Individual
Prefix:MS
First Name:LAURA
Middle Name:ANN
Last Name:EVANS
Suffix:
Gender:F
Credentials:NCTM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1053 GRAND AVE
Mailing Address - Street 2:SUITE 109
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55105-3022
Mailing Address - Country:US
Mailing Address - Phone:651-964-3446
Mailing Address - Fax:
Practice Address - Street 1:1053 GRAND AVE
Practice Address - Street 2:SUITE 109
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55105-3022
Practice Address - Country:US
Practice Address - Phone:651-964-3446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN20120000495225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist