Healthcare Provider Details

I. General information

NPI: 1083931273
Provider Name (Legal Business Name): LAURA R O'BRYAN LDEM, CPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2010
Last Update Date: 05/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5417 S KNOLLCREST ST
MURRAY UT
84107-6208
US

IV. Provider business mailing address

5417 S KNOLLCREST ST
MURRAY UT
84107-6208
US

V. Phone/Fax

Practice location:
  • Phone: 801-330-9834
  • Fax:
Mailing address:
  • Phone: 801-330-9834
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number9428425-3400
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: