Provider Demographics
NPI:1184952848
Name:MABRY, LAURA THERESA (MSN, CNM)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:THERESA
Last Name:MABRY
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 N NILES AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-1924
Mailing Address - Country:US
Mailing Address - Phone:574-647-1610
Mailing Address - Fax:
Practice Address - Street 1:621 MEMORIAL DR STE 403
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1074
Practice Address - Country:US
Practice Address - Phone:574-647-1405
Practice Address - Fax:574-647-3970
Is Sole Proprietor?:No
Enumeration Date:2009-11-18
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN09000186A367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200976360Medicaid
IN236040259OtherMEDICARE PTAN
IN000000789440OtherBCBS BMG CENTENNIAL
IN000000667012OtherBCBS BMG CENTRAL
IN000000781007OtherBCBS BMG SOUTHEAST
IN178420015Medicare PIN
IN178410002Medicare PIN