Healthcare Provider Details

I. General information

NPI: 1245804863
Provider Name (Legal Business Name): MALIA ELIZABETH PUTZEL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2021
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4140 RICHARD AVE STE 200
HERMANTOWN MN
55811-3309
US

IV. Provider business mailing address

802 W COLLEGE ST APT 14
DULUTH MN
55811-4930
US

V. Phone/Fax

Practice location:
  • Phone: 218-514-5230
  • Fax:
Mailing address:
  • Phone: 218-290-9391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: