Provider Demographics
NPI:1396596482
Name:NYDEGGER, LOREN
Entity type:Individual
Prefix:
First Name:LOREN
Middle Name:
Last Name:NYDEGGER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 OAK RIDGE DR SE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IA
Mailing Address - Zip Code:52314-1585
Mailing Address - Country:US
Mailing Address - Phone:319-621-2602
Mailing Address - Fax:
Practice Address - Street 1:600 1ST ST SW
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:IA
Practice Address - Zip Code:52314-1098
Practice Address - Country:US
Practice Address - Phone:319-895-4573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-28
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA0007242255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer