Healthcare Provider Details

I. General information

NPI: 1679288591
Provider Name (Legal Business Name): LYANN LAVERGNE OHLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 01/20/2023
Certification Date: 01/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 JESSIE LN
NAMPA ID
83686-8863
US

IV. Provider business mailing address

4025 JESSIE LN
NAMPA ID
83686-8863
US

V. Phone/Fax

Practice location:
  • Phone: 760-455-1985
  • Fax:
Mailing address:
  • Phone: 760-455-1985
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: