Provider Demographics
NPI:1194175166
Name:MINNICK, LAUREN MISHEL (MS ATC)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:MISHEL
Last Name:MINNICK
Suffix:
Gender:F
Credentials:MS ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12531 EL DORADO PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-8063
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16500 MOJAVE DR
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-3822
Practice Address - Country:US
Practice Address - Phone:760-792-0861
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-20
Last Update Date:2016-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000235622255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer