Healthcare Provider Details

I. General information

NPI: 1073690012
Provider Name (Legal Business Name): MARY D MACKENBURG MOHN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 06/14/2022
Certification Date: 06/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 RIVERSIDE AVE
MINNEAPOLIS MN
55454-1450
US

IV. Provider business mailing address

2910 CENTRE POINTE DRIVE 35121A CHILDRENS HEALTH CARE
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 126-726-0006
  • Fax:
Mailing address:
  • Phone: 651-855-2327
  • Fax: 651-855-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR0933245
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0991736
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number0991736
License Number StateCO
# 4
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR0933245
License Number StateMN
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR0933245
License Number StateMN
# 6
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number2472
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: