Healthcare Provider Details

I. General information

NPI: 1750525424
Provider Name (Legal Business Name): LAURA LYNNE DERUITER RN,IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2009
Last Update Date: 04/27/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1809 N YOUNG RD
HART MI
49420-8843
US

IV. Provider business mailing address

1809 N YOUNG RD
HART MI
49420-8843
US

V. Phone/Fax

Practice location:
  • Phone: 231-873-3259
  • Fax: 231-873-8320
Mailing address:
  • Phone: 231-873-3259
  • Fax: 231-873-8320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number4704125868
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: