Healthcare Provider Details

I. General information

NPI: 1013787555
Provider Name (Legal Business Name): LAURA SPONG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/05/2024
Last Update Date: 01/05/2024
Certification Date: 01/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 CEDAR ST
SAINT PAUL MN
55101-2209
US

IV. Provider business mailing address

1857 HURON AVE
ROSEVILLE MN
55113-6135
US

V. Phone/Fax

Practice location:
  • Phone: 651-266-1343
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2470489
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: