Healthcare Provider Details

I. General information

NPI: 1073065538
Provider Name (Legal Business Name): ALEXIS RUPP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2016
Last Update Date: 12/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

16322 25TH ST S
LAKELAND MN
55043-9732
US

V. Phone/Fax

Practice location:
  • Phone: 612-365-1000
  • Fax:
Mailing address:
  • Phone: 651-329-1435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License NumberRN 18159-9
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 1993
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: