Provider Demographics
NPI:1679770754
Name:NORDVIK, MARY ANN EDELL (OTR)
Entity Type:Individual
Prefix:MRS
First Name:MARY ANN
Middle Name:EDELL
Last Name:NORDVIK
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5285 BROWNING DR
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82007-3553
Mailing Address - Country:US
Mailing Address - Phone:307-635-3846
Mailing Address - Fax:307-635-3846
Practice Address - Street 1:503 S 18TH ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4303
Practice Address - Country:US
Practice Address - Phone:307-742-3728
Practice Address - Fax:307-721-2002
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY641225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist