Provider Demographics
NPI:1043846751
Name:ABERNATHY, LAURA JEAN (LMT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JEAN
Last Name:ABERNATHY
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 ODAY ST N
Mailing Address - Street 2:
Mailing Address - City:MAPLEWOOD
Mailing Address - State:MN
Mailing Address - Zip Code:55119-4727
Mailing Address - Country:US
Mailing Address - Phone:651-226-7392
Mailing Address - Fax:
Practice Address - Street 1:7803 AFTON RD STE 17
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1507
Practice Address - Country:US
Practice Address - Phone:651-226-7392
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN927216225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty