Healthcare Provider Details

I. General information

NPI: 1053242438
Provider Name (Legal Business Name): LAURA BETH VERVAIN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

531 BRYDEN AVE
LEWISTON ID
83501-4438
US

IV. Provider business mailing address

531 BRYDEN AVE
LEWISTON ID
83501-4438
US

V. Phone/Fax

Practice location:
  • Phone: 208-798-1646
  • Fax: 208-798-5568
Mailing address:
  • Phone: 208-798-1646
  • Fax: 208-798-5568

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: