Provider Demographics
NPI:1417176785
Name:LURSEN, MONICA (REGISTERED DIETICIAN)
Entity type:Individual
Prefix:
First Name:MONICA
Middle Name:
Last Name:LURSEN
Suffix:
Gender:F
Credentials:REGISTERED DIETICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27924 BUTLER CENTER RD
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50619-9180
Mailing Address - Country:US
Mailing Address - Phone:319-352-4902
Mailing Address - Fax:
Practice Address - Street 1:312 9TH ST SW
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:IA
Practice Address - Zip Code:50677-2929
Practice Address - Country:US
Practice Address - Phone:319-352-4902
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00410133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA00410OtherIA LICENSE
IA368373OtherCDR