Healthcare Provider Details

I. General information

NPI: 1619778479
Provider Name (Legal Business Name): LAURA WIEDERHOEFT WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2025
Last Update Date: 03/16/2026
Certification Date: 03/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

671 VANDALIA ST
SAINT PAUL MN
55114-1312
US

IV. Provider business mailing address

1367 WILLOW ST APT 344
MINNEAPOLIS MN
55403-2583
US

V. Phone/Fax

Practice location:
  • Phone: 651-696-5674
  • Fax:
Mailing address:
  • Phone: 608-235-6375
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number12606
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: