Healthcare Provider Details

I. General information

NPI: 1336490929
Provider Name (Legal Business Name): CARLY FELICETTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2012
Last Update Date: 09/24/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8990 SPRINGBROOK DR NW #250
COON RAPIDS MN
55433
US

IV. Provider business mailing address

3358 LINCOLN ST NE
MINNEAPOLIS MN
55418-1454
US

V. Phone/Fax

Practice location:
  • Phone: 764-360-5348
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number091718
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: