Healthcare Provider Details

I. General information

NPI: 1902103658
Provider Name (Legal Business Name): NICOLLE MARIE UBAN PHD, APRN, CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

117 GILLIS AVE NE
BRAINERD MN
56401-3131
US

IV. Provider business mailing address

117 GILLIS AVE NE
BRAINERD MN
56401-3131
US

V. Phone/Fax

Practice location:
  • Phone: 218-828-7773
  • Fax: 218-828-2976
Mailing address:
  • Phone: 218-828-7773
  • Fax: 218-828-2976

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR 128894-4
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM0226
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: