Healthcare Provider Details

I. General information

NPI: 1619213527
Provider Name (Legal Business Name): TAMARA JO OBRIEN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/20/2012
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1025 MARSH ST
MANKATO MN
56001-4752
US

IV. Provider business mailing address

500 4TH AVE SE
WASECA MN
56093-3408
US

V. Phone/Fax

Practice location:
  • Phone: 507-625-4031
  • Fax:
Mailing address:
  • Phone: 507-833-2379
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR1290592
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: