Healthcare Provider Details

I. General information

NPI: 1144076183
Provider Name (Legal Business Name): LAURYN RENEE CAULLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 PINE TREE DR
ARDEN HILLS MN
55112-3754
US

IV. Provider business mailing address

3324 YATES AVE N
CRYSTAL MN
55422-2617
US

V. Phone/Fax

Practice location:
  • Phone: 651-635-8000
  • Fax:
Mailing address:
  • Phone: 763-370-2612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number15494
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: