Healthcare Provider Details

I. General information

NPI: 1851373609
Provider Name (Legal Business Name): NICOLE M LAVANTY MSPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/17/2005
Last Update Date: 11/19/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

715 S 8TH ST FL 3
MINNEAPOLIS MN
55404-7530
US

IV. Provider business mailing address

6515 BARRIE RD SUITE 100
EDINA MN
55435-2305
US

V. Phone/Fax

Practice location:
  • Phone: 612-873-4524
  • Fax: 612-873-1608
Mailing address:
  • Phone: 952-922-5019
  • Fax: 952-922-1384

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number7672
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: