MEDICARE: MS. CHARLOTTE LOUISE STACK R.N., CNS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SP0809X	Adult Psychiatric/Mental Health Clinical Nurse Specialist	R0917850	MN

General Provider Information

NPI Number	:	1700955648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CHARLOTTE LOUISE STACK R.N., CNS

Provider Business Mailing Address
First Line	:	573 N DAY RD
Second Line	:
City	:	SAINT CROIX FALLS
State	:	WI
Zip	:	54024-9454
Country	:	US
Telephone Number	:	715-483-9688
Fax Number	:	651-464-5744

Provider Business Practice Location Address
First Line	:	882 SW 15TH ST.
Second Line	:
City	:	FOREST LAKE
State	:	MN
Zip	:	55025-1331
Country	:	US
Telephone Number	:	651-464-2194
Fax Number	:	651-464-5744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/07/2006
Last Update Date	:	07/08/2007

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