Healthcare Provider Details

I. General information

NPI: 1245682228
Provider Name (Legal Business Name): LAURIE ANNE RODENBERG CNM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2016
Last Update Date: 05/21/2020
Certification Date: 05/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17722 TALBOT RD S
RENTON WA
98055-5744
US

IV. Provider business mailing address

3600 LIND AVE SW SUITE 100 ATTN CREDENTIALING
RENTON WA
98057-4970
US

V. Phone/Fax

Practice location:
  • Phone: 425-690-3479
  • Fax: 425-690-9479
Mailing address:
  • Phone: 425-690-2715
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberC-APN.0000940-C-CNM
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberN361050020
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number2016022819
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: