Provider Demographics
NPI:1639135528
Name:RIEDEL, LAUREL J (CNM)
Entity Type:Individual
Prefix:
First Name:LAUREL
Middle Name:J
Last Name:RIEDEL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55415-1623
Mailing Address - Country:US
Mailing Address - Phone:612-873-6005
Mailing Address - Fax:612-630-8242
Practice Address - Street 1:701 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55415-1623
Practice Address - Country:US
Practice Address - Phone:612-873-2203
Practice Address - Fax:612-904-4273
Is Sole Proprietor?:No
Enumeration Date:2006-04-21
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN05120367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN116097OtherUCARE
MN46G44RIOtherBLUE CROSS BLUE SHIELD
MN07-40100OtherMEDICA
MN718840400Medicaid
MN718840400Medicaid
MN116097OtherUCARE
MNS09968Medicare UPIN