Healthcare Provider Details

I. General information

NPI: 1780498253
Provider Name (Legal Business Name): LAURA MARIE DELAGE CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/05/2025
Last Update Date: 02/05/2025
Certification Date: 01/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 4TH STREET
MAHNOMEN MN
56557
US

IV. Provider business mailing address

106 STEPHEN DR SE
FERTILE MN
56540-4117
US

V. Phone/Fax

Practice location:
  • Phone: 218-935-2514
  • Fax:
Mailing address:
  • Phone: 218-521-0644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number12378
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: