Healthcare Provider Details

I. General information

NPI: 1528038106
Provider Name (Legal Business Name): AMY S LANGE CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LAGOON AVE
MINNEAPOLIS MN
55408-2077
US

IV. Provider business mailing address

4043 COLFAX AVE S
MINNEAPOLIS MN
55409-1425
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-6300
  • Fax:
Mailing address:
  • Phone: 612-822-8136
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberR1113365
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: