Healthcare Provider Details

I. General information

NPI: 1497739247
Provider Name (Legal Business Name): KARA LEE MAUCIERI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KARA LEE DAHLEN

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/19/2020
Certification Date: 11/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 E MAIN ST
CROSBY MN
56441-1645
US

IV. Provider business mailing address

320 E MAIN ST
CROSBY MN
56441-1645
US

V. Phone/Fax

Practice location:
  • Phone: 218-546-7000
  • Fax: 218-545-4456
Mailing address:
  • Phone: 218-546-7000
  • Fax: 218-545-4456

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number38856
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: