Healthcare Provider Details

I. General information

NPI: 1245575984
Provider Name (Legal Business Name): MARY PATRICIA STEVENS RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2012
Last Update Date: 12/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 MALL DR
DULUTH MN
55811-3849
US

IV. Provider business mailing address

1700 MALL DR
DULUTH MN
55811-3849
US

V. Phone/Fax

Practice location:
  • Phone: 218-727-0990
  • Fax: 218-727-1179
Mailing address:
  • Phone: 218-727-0990
  • Fax: 218-727-1179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR122590-7
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number110340-30
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: