Healthcare Provider Details

I. General information

NPI: 1568789352
Provider Name (Legal Business Name): LAURA MICHELLE NILAN DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 06/12/2023
Certification Date: 06/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8100 NORTHLAND DR
BLOOMINGTON MN
55431-4800
US

IV. Provider business mailing address

8170 33RD AVE S # 21110
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-831-8742
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2013018502
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2080S0010X
TaxonomyPediatric Sports Medicine Physician
License Number62719
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: