Healthcare Provider Details

I. General information

NPI: 1275649873
Provider Name (Legal Business Name): LAURIE JEAN WHITBECK LPN, OPA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LAURIE JEAN NELSON LPN, OPA-C

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 07/11/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

775 PRAIRIE CENTER DR SUITE 250
EDEN PRAIRIE MN
55344-7314
US

IV. Provider business mailing address

6465 WAYZATA BLVD SUITE 900
ST LOUIS PARK MN
55426-1728
US

V. Phone/Fax

Practice location:
  • Phone: 952-944-2519
  • Fax: 952-944-0460
Mailing address:
  • Phone: 952-512-5600
  • Fax: 952-512-5650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SM0705X
TaxonomyMedical-Surgical Clinical Nurse Specialist
License NumberL0264862
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: