Provider Demographics
NPI:1962733410
Name:SEVERSON, GARY LAVERNE (RN)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:LAVERNE
Last Name:SEVERSON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2925 JOHNSON AVE NW TRLR 50
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52405-4676
Mailing Address - Country:US
Mailing Address - Phone:319-981-3617
Mailing Address - Fax:
Practice Address - Street 1:2925 JOHNSON AVE NW TRLR 50
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52405-4676
Practice Address - Country:US
Practice Address - Phone:319-981-3617
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-22
Last Update Date:2010-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA087661163WH0200X, 163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy