Healthcare Provider Details

I. General information

NPI: 1588542245
Provider Name (Legal Business Name): KENYATA TYESHIA CARROLL FNP, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 E 35TH ST
MINNEAPOLIS MN
55408-4580
US

IV. Provider business mailing address

6828 RUSSELL AVE S
RICHFIELD MN
55423-2022
US

V. Phone/Fax

Practice location:
  • Phone: 612-827-7181
  • Fax: 612-767-4545
Mailing address:
  • Phone: 763-464-9711
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number12819
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: