Provider Demographics
NPI:1306893136
Name:NYSTROM, AMY LORRAINE (LAC)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:LORRAINE
Last Name:NYSTROM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:101 LAKE ST W
Mailing Address - Street 2:100
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1576
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 LAKE ST W
Practice Address - Street 2:100
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1576
Practice Address - Country:US
Practice Address - Phone:952-473-4241
Practice Address - Fax:952-473-5415
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN1099171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist