Healthcare Provider Details

I. General information

NPI: 1073278776
Provider Name (Legal Business Name): MADELINE JOLEAHBETH LESLYN KURTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2021
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4900 US-169 SUITE 100
MINNEAPOLIS MN
55428
US

IV. Provider business mailing address

4900 US-169 100
MINNEAPOLIS MN
55428
US

V. Phone/Fax

Practice location:
  • Phone: 651-773-5988
  • Fax:
Mailing address:
  • Phone: 612-877-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number202668
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number202668
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: