Healthcare Provider Details

I. General information

NPI: 1851927180
Provider Name (Legal Business Name): LAURA BETH MULCAHY CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2020
Last Update Date: 09/10/2024
Certification Date: 09/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2023 VADALABENE DR STE 200
MARYVILLE IL
62062-5636
US

IV. Provider business mailing address

2023 VADALABENE DR
MARYVILLE IL
62062-5630
US

V. Phone/Fax

Practice location:
  • Phone: 618-288-7408
  • Fax: 618-288-7418
Mailing address:
  • Phone: 618-288-7408
  • Fax: 618-288-7418

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2020009853
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: