Healthcare Provider Details

I. General information

NPI: 1396139937
Provider Name (Legal Business Name): LAUREN DYBWAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2015
Last Update Date: 03/20/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2605 N WICKERSHAM DR
MUNCIE IN
47304-9226
US

IV. Provider business mailing address

2605 N WICKERSHAM DR
MUNCIE IN
47304-9226
US

V. Phone/Fax

Practice location:
  • Phone: 765-717-9383
  • Fax:
Mailing address:
  • Phone: 765-717-9383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: