Provider Demographics
NPI:1629218227
Name:COULTER, LAURA (CNM/APN, MS, IBCLC)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:COULTER
Suffix:
Gender:F
Credentials:CNM/APN, MS, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4538 N HERMITAGE AVE
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60640-5304
Mailing Address - Country:US
Mailing Address - Phone:312-320-3996
Mailing Address - Fax:
Practice Address - Street 1:4538 N HERMITAGE AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60640-5304
Practice Address - Country:US
Practice Address - Phone:312-320-3996
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-23
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-003413367A00000X
IL041-291976163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant