Healthcare Provider Details

I. General information

NPI: 1528033149
Provider Name (Legal Business Name): SHERRY M MARINELLO PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2006
Last Update Date: 08/11/2021
Certification Date: 08/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15245 BLUEBIRD ST NW
ANDOVER MN
55304-3538
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 763-587-4600
  • Fax: 763-587-4615
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number9433
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: