Healthcare Provider Details

I. General information

NPI: 1568594489
Provider Name (Legal Business Name): LAURA JANE HERMANN PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 DELLWOOD ST S
CAMBRIDGE MN
55008-1920
US

IV. Provider business mailing address

23410 FONTANA ST NE
STACY MN
55079-9342
US

V. Phone/Fax

Practice location:
  • Phone: 763-689-7782
  • Fax:
Mailing address:
  • Phone: 651-462-1494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: