Healthcare Provider Details

I. General information

NPI: 1396288577
Provider Name (Legal Business Name): ROSE SOLLY NURSE PRACTITIONER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2016
Last Update Date: 08/30/2022
Certification Date: 08/30/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3805 WASHINGTON AVE N
MINNEAPOLIS MN
55412-2141
US

IV. Provider business mailing address

3805 WASHINGTON AVE N
MINNEAPOLIS MN
55412-2141
US

V. Phone/Fax

Practice location:
  • Phone: 612-887-6282
  • Fax: 612-437-4992
Mailing address:
  • Phone: 128-876-2826
  • Fax: 612-437-4992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 174081-9
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number6735
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: