Provider Demographics
NPI:1790276798
Name:LAMBORN, MINDY RENEE
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:RENEE
Last Name:LAMBORN
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 1:1660 WYOMING AVE
Mailing Address - Street 2:
Mailing Address - City:LARAMIE
Mailing Address - State:WY
Mailing Address - Zip Code:82070-7144
Mailing Address - Country:US
Mailing Address - Phone:307-760-3058
Mailing Address - Fax:
Practice Address - Street 1:807 S 3RD ST
Practice Address - Street 2:
Practice Address - City:LARAMIE
Practice Address - State:WY
Practice Address - Zip Code:82070-4419
Practice Address - Country:US
Practice Address - Phone:307-721-2050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-24
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty