=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568976835
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE LAUREANO LMT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/25/2017
-----------------------------------------------------
Last Update Date | 02/17/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3911 OUTLOOK BLVD STE B
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81008-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-406-0794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3911 OUTLOOK BLVD STE B
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81008-1624
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-406-0794
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | MT.0020303
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------