Provider Demographics
NPI:1689204257
Name:STAR, LAURA
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:STAR
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 1:8190 S GIFFIN LN
Mailing Address - Street 2:
Mailing Address - City:LAKE NEBAGAMON
Mailing Address - State:WI
Mailing Address - Zip Code:54849-9049
Mailing Address - Country:US
Mailing Address - Phone:218-590-4060
Mailing Address - Fax:
Practice Address - Street 1:8190 S GIFFIN LN
Practice Address - Street 2:
Practice Address - City:LAKE NEBAGAMON
Practice Address - State:WI
Practice Address - Zip Code:54849-9049
Practice Address - Country:US
Practice Address - Phone:218-590-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-22
Last Update Date:2020-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer