Healthcare Provider Details

I. General information

NPI: 1073924593
Provider Name (Legal Business Name): KAREN MACDONALD DE JONG RN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2014
Last Update Date: 05/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

IV. Provider business mailing address

701 PARK AVE
MINNEAPOLIS MN
55415-1623
US

V. Phone/Fax

Practice location:
  • Phone: 612-807-5200
  • Fax:
Mailing address:
  • Phone: 612-807-5200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberR090261-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: