=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699214247
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LUNA WOMEN'S WELLNESS AND BIRTH CENTER PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2017
-----------------------------------------------------
Last Update Date | 02/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 117 GILLIS AVE NE
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-3131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-828-7773
-----------------------------------------------------
Fax | 218-828-2976
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 117 GILLIS AVE NE
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-3131
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-828-7773
-----------------------------------------------------
Fax | 218-828-2976
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | NICOLLE M UBAN
-----------------------------------------------------
Credential | PHD, CNM, APRN
-----------------------------------------------------
Telephone | 218-828-7773
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 176B00000X
-----------------------------------------------------
Taxonomy Name | Midwife
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------