Healthcare Provider Details

I. General information

NPI: 1598778953
Provider Name (Legal Business Name): MARY T O'DONNELL CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 05/01/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3074
US

IV. Provider business mailing address

2001 BLOOMINGTON AVE
MINNEAPOLIS MN
55404-3074
US

V. Phone/Fax

Practice location:
  • Phone: 612-301-3433
  • Fax: 612-627-4205
Mailing address:
  • Phone: 612-301-3433
  • Fax: 612-627-4205

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR138388-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: