Provider Demographics
NPI:1699245779
Name:MOLIERI, LAUREN
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:
Last Name:MOLIERI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5236 134TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:ND
Mailing Address - Zip Code:58801-8807
Mailing Address - Country:US
Mailing Address - Phone:610-787-0942
Mailing Address - Fax:
Practice Address - Street 1:1515 2ND AVE W
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:ND
Practice Address - Zip Code:58801-4108
Practice Address - Country:US
Practice Address - Phone:701-572-6766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1273A225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant