Healthcare Provider Details

I. General information

NPI: 1659763928
Provider Name (Legal Business Name): TERESA CYRUS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2015
Last Update Date: 10/29/2024
Certification Date: 10/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7401 METRO BLVD STE 250
EDINA MN
55439-3062
US

IV. Provider business mailing address

21897 S DIAMOND LAKE RD STE 400-403
ROGERS MN
55374-4642
US

V. Phone/Fax

Practice location:
  • Phone: 612-268-5858
  • Fax:
Mailing address:
  • Phone: 763-317-1122
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP 3692
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3692
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: