Healthcare Provider Details

I. General information

NPI: 1992960819
Provider Name (Legal Business Name): KRISTIN COLE SORENSEN-TANENBAUM NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KRISTIN MARY SORENSEN-TANENBAUM FNP-C, PMH-NP

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 09/28/2020
Certification Date: 09/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 SE 13TH ST
GRAND RAPIDS MN
55744-0015
US

IV. Provider business mailing address

3125 WILLIVAN WOODS
GRAND RAPIDS MN
55744-8661
US

V. Phone/Fax

Practice location:
  • Phone: 218-999-9908
  • Fax:
Mailing address:
  • Phone: 301-741-6101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5112
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR160645
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR160645
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: