Healthcare Provider Details

I. General information

NPI: 1891552006
Provider Name (Legal Business Name): LORI LYNN SYVERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/04/2024
Last Update Date: 03/04/2024
Certification Date: 03/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 N. CRUSEY ST. STE A101
WASILLA AK
99654
US

IV. Provider business mailing address

77 N. CRUSEY ST. STE A101
WASILLA AK
99654
US

V. Phone/Fax

Practice location:
  • Phone: 907-315-5425
  • Fax:
Mailing address:
  • Phone: 907-315-5425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: