Healthcare Provider Details

I. General information

NPI: 1073490652
Provider Name (Legal Business Name): LAUREN HEIDENREICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2025
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 E OAKLAND AVE STE B
BLOOMINGTON IL
61701-5783
US

IV. Provider business mailing address

9669 N 1600 EAST RD
BLOOMINGTON IL
61705-5503
US

V. Phone/Fax

Practice location:
  • Phone: 309-808-3068
  • Fax:
Mailing address:
  • Phone: 309-826-9226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number209032987
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: