Healthcare Provider Details

I. General information

NPI: 1104736552
Provider Name (Legal Business Name): LARISA KULMANOVSKY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 HARVARD ST SE
MINNEAPOLIS MN
55455-0353
US

IV. Provider business mailing address

308 HARVARD ST SE
MINNEAPOLIS MN
55455-0353
US

V. Phone/Fax

Practice location:
  • Phone: 612-624-9600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2522464
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: