MEDICARE: LAKOU TYRA TRAY RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WH0200X	Home Health Registered Nurse	2504716	MN

General Provider Information

NPI Number	:	1912865064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAKOU TYRA TRAY RN

Provider Business Mailing Address
First Line	:	3570 LEXINGTON AVE N STE 204
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-8049
Country	:	US
Telephone Number	:	612-886-6701
Fax Number	:	612-439-5374

Provider Business Practice Location Address
First Line	:	3570 LEXINGTON AVE N STE 204
Second Line	:
City	:	SHOREVIEW
State	:	MN
Zip	:	55126-8049
Country	:	US
Telephone Number	:	612-886-6701
Fax Number	:	612-439-5374

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/15/2026
Last Update Date	:	01/15/2026

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