Basic Information
| Provider Information | |||||||||
| NPI: | 1417952540 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FLETT | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | ANN SAYLOR | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | THERAPY | ||||||||
| OtherFirstName: | YREKA PHYSICAL | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1226 | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960971226 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424381 | ||||||||
| FaxNumber: | 5308429054 | ||||||||
| Practice Location | |||||||||
| Address1: | 205 EXECUTIVE CT | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960972629 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424381 | ||||||||
| FaxNumber: | 5308429054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2005 | ||||||||
| LastUpdateDate: | 07/23/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 03/18/2006 | ||||||||
| NPIReactivationDate: | 03/27/2006 | ||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PT9272 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | PT0092720 | 05 | CA | MEDICAID |