=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679770754
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARY ANN EDELL NORDVIK OTR
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 503 S 18TH ST
-----------------------------------------------------
City | LARAMIE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82070-4303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-742-3728
-----------------------------------------------------
Fax | 307-721-2002
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5285 BROWNING DR
-----------------------------------------------------
City | CHEYENNE
-----------------------------------------------------
State | WY
-----------------------------------------------------
Zip | 82007-3553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 307-635-3846
-----------------------------------------------------
Fax | 307-635-3846
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225X00000X
-----------------------------------------------------
Taxonomy Name | Occupational Therapist
-----------------------------------------------------
License Number | 641
-----------------------------------------------------
License Number State | WY
-----------------------------------------------------