Provider Demographics
NPI:1811512650
Name:VANGORP, LAUREN OLIVIA (PT, DPT)
Entity type:Individual
Prefix:
First Name:LAUREN
Middle Name:OLIVIA
Last Name:VANGORP
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8048 WATERCRESS AVE
Mailing Address - Street 2:
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83687-8289
Mailing Address - Country:US
Mailing Address - Phone:219-713-2486
Mailing Address - Fax:
Practice Address - Street 1:5418 N EAGLE RD STE 170
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83713-0999
Practice Address - Country:US
Practice Address - Phone:208-501-8264
Practice Address - Fax:208-514-1558
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDPT-6706225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist