Healthcare Provider Details

I. General information

NPI: 1427929124
Provider Name (Legal Business Name): KALISA RURINDA NDIKUBWIMANA DNP-CNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2025
Last Update Date: 09/16/2025
Certification Date: 09/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1725 LEGACY PKWY E STE 100
MAPLEWOOD MN
55109-5434
US

IV. Provider business mailing address

1725 LEGACY PKWY E STE 100
MAPLEWOOD MN
55109-5434
US

V. Phone/Fax

Practice location:
  • Phone: 952-234-8580
  • Fax: 952-841-2346
Mailing address:
  • Phone: 952-234-8580
  • Fax: 952-841-2346

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number13025
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13025
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: