Healthcare Provider Details

I. General information

NPI: 1104715044
Provider Name (Legal Business Name): ELISE MINCKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2025
Last Update Date: 07/02/2025
Certification Date: 07/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 VETERANS DR
MINNEAPOLIS MN
55417-2309
US

IV. Provider business mailing address

6775 245TH ST W
FARMINGTON MN
55024-9646
US

V. Phone/Fax

Practice location:
  • Phone: 612-467-6779
  • Fax:
Mailing address:
  • Phone: 612-210-5440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number2431884
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: