Provider Demographics
NPI:1699218636
Name:MANACK, LAURE
Entity Type:Individual
Prefix:
First Name:LAURE
Middle Name:
Last Name:MANACK
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:PO BOX 5010
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58702-5010
Mailing Address - Country:US
Mailing Address - Phone:701-857-5650
Mailing Address - Fax:701-857-5031
Practice Address - Street 1:307 1ST AVE NW
Practice Address - Street 2:TRINITY COMMUNITY CLINIC - KENMARE
Practice Address - City:KENMARE
Practice Address - State:ND
Practice Address - Zip Code:58746-7104
Practice Address - Country:US
Practice Address - Phone:701-385-4283
Practice Address - Fax:701-385-4282
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-23
Last Update Date:2017-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR43934363LF0000X
TXAP132430363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily