Healthcare Provider Details

I. General information

NPI: 1184952848
Provider Name (Legal Business Name): LAURA THERESA MABRY MSN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2009
Last Update Date: 04/28/2023
Certification Date: 04/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 MEMORIAL DR STE 403
SOUTH BEND IN
46601-1074
US

IV. Provider business mailing address

710 N NILES AVE
SOUTH BEND IN
46617-1924
US

V. Phone/Fax

Practice location:
  • Phone: 574-647-1405
  • Fax: 574-647-3970
Mailing address:
  • Phone: 574-647-1610
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number09000186A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: