Healthcare Provider Details

I. General information

NPI: 1851373880
Provider Name (Legal Business Name): LAURA L BLOOMQUIST M. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2005
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1675 COUNTY 6
LA CRESCENT MN
55947-9720
US

IV. Provider business mailing address

PO BOX 265
LA CROSSE WI
54602-0265
US

V. Phone/Fax

Practice location:
  • Phone: 608-790-0758
  • Fax: 608-787-8911
Mailing address:
  • Phone: 608-790-0758
  • Fax: 608-787-8911

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number31249
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: