Healthcare Provider Details

I. General information

NPI: 1720565617
Provider Name (Legal Business Name): ELAINE MARY THELEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2018
Last Update Date: 07/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

525 MAIN ST W
MELROSE MN
56352-1043
US

IV. Provider business mailing address

525 MAIN ST W
MELROSE MN
56352
US

V. Phone/Fax

Practice location:
  • Phone: 320-256-4231
  • Fax:
Mailing address:
  • Phone: 320-256-4231
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6015
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: