Provider Demographics
NPI:1720485329
Name:WIESE, LAURA MARIE (CNM)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MARIE
Last Name:WIESE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:MARIE
Other - Last Name:GENETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 70368
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97475-0120
Mailing Address - Country:US
Mailing Address - Phone:541-485-2777
Mailing Address - Fax:541-246-2353
Practice Address - Street 1:3100 MARTIN LUTHER KING JR PKWY
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-7514
Practice Address - Country:US
Practice Address - Phone:541-868-9700
Practice Address - Fax:541-485-7392
Is Sole Proprietor?:No
Enumeration Date:2014-11-25
Last Update Date:2023-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR100002649367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife