Provider Demographics
NPI:1083867873
Name:CONRAN, LAURA ANN-ENNIS (DPT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN-ENNIS
Last Name:CONRAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:
Other - Last Name:ENNIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2120 43RD ST SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508
Mailing Address - Country:US
Mailing Address - Phone:616-281-1144
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW
Practice Address - Street 2:SUITE A
Practice Address - City:GRANDVILLE
Practice Address - State:MI
Practice Address - Zip Code:49418
Practice Address - Country:US
Practice Address - Phone:616-855-1495
Practice Address - Fax:616-531-5027
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-24
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI5501014115225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist