Healthcare Provider Details

I. General information

NPI: 1932174828
Provider Name (Legal Business Name): KATY MARIE SCHALLA LESIAK CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: KATY MARIE SCHALLA LESIAK

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE S CHILDRENS PRIMARY CLINIC MPLS
MINNEAPOLIS MN
55404
US

IV. Provider business mailing address

2910 CENTRE POINTE DR 35-121A CHILDRENS HEALTH CARE
ROSEVILLE MN
55113
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-6107
  • Fax: 612-813-7473
Mailing address:
  • Phone: 651-855-2109
  • Fax: 651-855-2310

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR1481301
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: