Healthcare Provider Details

I. General information

NPI: 1821964214
Provider Name (Legal Business Name): LAURA A MICKELSON PHD, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2025
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR # 118
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

1 VETERANS DR # 118
MINNEAPOLIS MN
55417-2309
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-1022
  • Fax:
Mailing address:
  • Phone: 612-467-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number1107449
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: