Healthcare Provider Details

I. General information

NPI: 1124129598
Provider Name (Legal Business Name): MICHELLE MARIE FERN RPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/26/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 MINNESOTA AVE THERAPY CONNECTIONS FOR KIDS
LITTLE CANADA MN
55117-1781
US

IV. Provider business mailing address

1951 FREMONT AVE E
SAINT PAUL MN
55119-4013
US

V. Phone/Fax

Practice location:
  • Phone: 651-206-3697
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5301
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number5402
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: