Provider Demographics
NPI:1639769284
Name:SHIRLEY, LAURA RAE (CNP)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:RAE
Last Name:SHIRLEY
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:RAE
Other - Last Name:WATSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 1ST ST SW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55905-0001
Mailing Address - Country:US
Mailing Address - Phone:507-377-6285
Mailing Address - Fax:
Practice Address - Street 1:701 HEWITT BLVD
Practice Address - Street 2:
Practice Address - City:RED WING
Practice Address - State:MN
Practice Address - Zip Code:55066-2848
Practice Address - Country:US
Practice Address - Phone:507-377-6285
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-18
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8536363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner