Healthcare Provider Details

I. General information

NPI: 1255747648
Provider Name (Legal Business Name): LAURA LEATHERMAN CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURA LEATHERMAN-CLARK CNM

II. Dates (important events)

Enumeration Date: 07/07/2014
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2635 UNIVERSITY AVE W STE 160
SAINT PAUL MN
55114-1271
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License NumberAPN0000018785
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number281
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: