Healthcare Provider Details

I. General information

NPI: 1104585744
Provider Name (Legal Business Name): TARA MARIE NORDBERG FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/10/2021
Last Update Date: 02/20/2026
Certification Date: 02/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15650 CEDAR AVE
APPLE VALLEY MN
55124-7283
US

IV. Provider business mailing address

15650 CEDAR AVE
APPLE VALLEY MN
55124-7283
US

V. Phone/Fax

Practice location:
  • Phone: 612-672-6000
  • Fax:
Mailing address:
  • Phone: 612-672-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11426
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: