Healthcare Provider Details

I. General information

NPI: 1750115036
Provider Name (Legal Business Name): ELLEN RAE COCHRAN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 08/28/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

28 NW 4TH ST STE A
GRAND RAPIDS MN
55744-2714
US

IV. Provider business mailing address

19569 PINE LANDING DR
GRAND RAPIDS MN
55744-5146
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-7750
  • Fax:
Mailing address:
  • Phone: 218-360-9466
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number12029
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: