Provider Demographics
NPI:1609609072
Name:WADSWORTH LUNDQUIST, LAURA ANN (BS, BSN, RN, IBCLC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:WADSWORTH LUNDQUIST
Suffix:
Gender:F
Credentials:BS, BSN, RN, IBCLC
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:LUNDQUIST
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:396 PHILBIN RD
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83202-7071
Mailing Address - Country:US
Mailing Address - Phone:208-241-1013
Mailing Address - Fax:
Practice Address - Street 1:396 PHILBIN RD
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83202-7071
Practice Address - Country:US
Practice Address - Phone:208-241-1013
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-21
Last Update Date:2024-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDN-44334163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation ConsultantGroup - Single Specialty