Healthcare Provider Details

I. General information

NPI: 1770417362
Provider Name (Legal Business Name): LAURA FAWN LIBBY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21100 OLINDA TRL N
SCANDIA MN
55073-9622
US

IV. Provider business mailing address

13320 195TH ST N
MARINE ON SAINT CROIX MN
55047-9710
US

V. Phone/Fax

Practice location:
  • Phone: 651-270-6140
  • Fax:
Mailing address:
  • Phone: 612-805-6286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: