Provider Demographics
NPI:1851373609
Name:LAVANTY, NICOLE M (MSPT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:LAVANTY
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6515 BARRIE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2305
Mailing Address - Country:US
Mailing Address - Phone:952-922-5019
Mailing Address - Fax:952-922-1384
Practice Address - Street 1:715 S 8TH ST FL 3
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-7530
Practice Address - Country:US
Practice Address - Phone:612-873-4524
Practice Address - Fax:612-873-1608
Is Sole Proprietor?:No
Enumeration Date:2005-11-17
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7672225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist