Provider Demographics
NPI:1093267189
Name:LUNA WOMEN'S WELLNESS AND BIRTH CENTER PC
Entity Type:Organization
Organization Name:LUNA WOMEN'S WELLNESS AND BIRTH CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MIDWIFE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:NICOLLE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:UBAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, APRN, CNM
Authorized Official - Phone:218-828-7773
Mailing Address - Street 1:117 GILLIS AVE NE
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401
Mailing Address - Country:US
Mailing Address - Phone:218-828-7773
Mailing Address - Fax:
Practice Address - Street 1:117 GILLIS AVE NE
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-3131
Practice Address - Country:US
Practice Address - Phone:218-828-7773
Practice Address - Fax:218-828-2976
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-25
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN32831261QB0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QB0400XAmbulatory Health Care FacilitiesClinic/CenterBirthing
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1902103658OtherINDIVIDUAL NPI