Provider Demographics
NPI:1659688240
Name:ST AUBIN, AMANDA KATHRYN (CNM)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:KATHRYN
Last Name:ST AUBIN
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 1:1000 E 1ST ST STE LL
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2297
Mailing Address - Country:US
Mailing Address - Phone:218-249-4700
Mailing Address - Fax:218-722-5148
Practice Address - Street 1:1000 E 1ST ST STE LL
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2297
Practice Address - Country:US
Practice Address - Phone:218-249-4700
Practice Address - Fax:218-722-5148
Is Sole Proprietor?:No
Enumeration Date:2010-09-03
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN169472-9163W00000X
MNCNM 0329367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
320059Medicare Oscar/Certification