Healthcare Provider Details

I. General information

NPI: 1083446876
Provider Name (Legal Business Name): PATRICIA SODERLUND NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2024
Last Update Date: 08/19/2024
Certification Date: 08/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E SUPERIOR ST STE 502
DULUTH MN
55802-2200
US

IV. Provider business mailing address

2531 E 4TH ST
DULUTH MN
55812-1435
US

V. Phone/Fax

Practice location:
  • Phone: 218-663-2600
  • Fax:
Mailing address:
  • Phone: 949-547-6510
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License Number11409
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11409
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number11409
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: