Provider Demographics
NPI:1720072234
Name:HART, LAURA ELLEN (MSN FNP CPNP)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:ELLEN
Last Name:HART
Suffix:
Gender:F
Credentials:MSN FNP CPNP
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ELLEN
Other - Last Name:COFFMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN FNP CPNP
Mailing Address - Street 1:4436 VINCENT AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55410-1526
Mailing Address - Country:US
Mailing Address - Phone:612-920-0207
Mailing Address - Fax:
Practice Address - Street 1:12450 WAYZATA BLVD
Practice Address - Street 2:SUITE 215 RIDGE PLAZA
Practice Address - City:MINNETONKA
Practice Address - State:MN
Practice Address - Zip Code:55305-1978
Practice Address - Country:US
Practice Address - Phone:952-546-6866
Practice Address - Fax:952-512-0038
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2009-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR098456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
500003052Medicare ID - Type Unspecified
MN500003052Medicare PIN
Q43949Medicare UPIN