Provider Demographics
NPI:1669980173
Name:BRANDVIK, LAURA S (LPN)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:S
Last Name:BRANDVIK
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:S
Other - Last Name:RAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:52075 S COUNTY ROAD 199
Mailing Address - Street 2:
Mailing Address - City:WOODWARD
Mailing Address - State:OK
Mailing Address - Zip Code:73801-5693
Mailing Address - Country:US
Mailing Address - Phone:580-374-2615
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1
Practice Address - Street 2:
Practice Address - City:FORT SUPPLY
Practice Address - State:OK
Practice Address - Zip Code:73841-0001
Practice Address - Country:US
Practice Address - Phone:580-766-2311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2018-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK0056276164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse