Healthcare Provider Details

I. General information

NPI: 1013811066
Provider Name (Legal Business Name): FATU CANDY GAYE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/05/2026
Last Update Date: 10/05/2026
Certification Date: 10/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1300 W LAKE ST UNIT 612
MINNEAPOLIS MN
55408-7212
US

IV. Provider business mailing address

1300 W LAKE ST UNIT 612
MINNEAPOLIS MN
55408-7212
US

V. Phone/Fax

Practice location:
  • Phone: 763-283-1020
  • Fax:
Mailing address:
  • Phone: 763-283-1020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2543219
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: