Provider Demographics
NPI:1790163020
Name:MINNIS, LAURA LYNNE (LPN)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:LYNNE
Last Name:MINNIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 W 15TH ST
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4110
Mailing Address - Country:US
Mailing Address - Phone:231-342-5833
Mailing Address - Fax:
Practice Address - Street 1:311 W 15TH ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-4110
Practice Address - Country:US
Practice Address - Phone:231-342-5833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-06
Last Update Date:2015-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703076821164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse