Provider Demographics
NPI:1457178006
Name:VRIESMAN, LAURA ANN (IS)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:ANN
Last Name:VRIESMAN
Suffix:
Gender:F
Credentials:IS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 MADISON ST E
Mailing Address - Street 2:
Mailing Address - City:KIMBERLY
Mailing Address - State:ID
Mailing Address - Zip Code:83341-5103
Mailing Address - Country:US
Mailing Address - Phone:208-961-1992
Mailing Address - Fax:
Practice Address - Street 1:215 MADISON ST E
Practice Address - Street 2:
Practice Address - City:KIMBERLY
Practice Address - State:ID
Practice Address - Zip Code:83341-5103
Practice Address - Country:US
Practice Address - Phone:208-961-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-24
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist