Provider Demographics
NPI:1831301472
Name:NYBERG, LAURY (LPT, WCC)
Entity Type:Individual
Prefix:
First Name:LAURY
Middle Name:
Last Name:NYBERG
Suffix:
Gender:F
Credentials:LPT, WCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:850 2ND ST NW
Mailing Address - Street 2:
Mailing Address - City:AITKIN
Mailing Address - State:MN
Mailing Address - Zip Code:56431-1140
Mailing Address - Country:US
Mailing Address - Phone:218-927-2164
Mailing Address - Fax:218-927-6436
Practice Address - Street 1:850 2ND ST NW
Practice Address - Street 2:
Practice Address - City:AITKIN
Practice Address - State:MN
Practice Address - Zip Code:56431-1140
Practice Address - Country:US
Practice Address - Phone:218-927-2164
Practice Address - Fax:218-927-6436
Is Sole Proprietor?:No
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN4783225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52P25NYOtherBCBS PROVIDER NUMBER