Provider Demographics
NPI:1760247795
Name:NOLAN, MARY ANNE (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANNE
Last Name:NOLAN
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16577 KLAMATH TER
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-8425
Mailing Address - Country:US
Mailing Address - Phone:845-548-0327
Mailing Address - Fax:
Practice Address - Street 1:3460 WASHINGTON DR STE 102
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55122-4301
Practice Address - Country:US
Practice Address - Phone:651-338-3574
Practice Address - Fax:651-683-2906
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2065171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist