Provider Demographics
NPI:1982683215
Name:LAUMB, KELLIE J (PAC)
Entity Type:Individual
Prefix:
First Name:KELLIE
Middle Name:J
Last Name:LAUMB
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33 9TH ST W
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-3993
Mailing Address - Country:US
Mailing Address - Phone:701-483-6017
Mailing Address - Fax:701-483-5018
Practice Address - Street 1:33 9TH ST W
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-3993
Practice Address - Country:US
Practice Address - Phone:701-483-6017
Practice Address - Fax:701-483-5018
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDPAC0323363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NDPAC0323OtherLICENSE
NDPAC0323OtherLICENSE