Healthcare Provider Details

I. General information

NPI: 1619233632
Provider Name (Legal Business Name): CARRIE JEAN GRANBOIS CNP, APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2012
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2911 26TH AVE S
MINNEAPOLIS MN
55406-1555
US

IV. Provider business mailing address

2911 26TH AVE S
MINNEAPOLIS MN
55406-1555
US

V. Phone/Fax

Practice location:
  • Phone: 612-886-3626
  • Fax: 612-886-3627
Mailing address:
  • Phone: 612-886-3626
  • Fax: 612-886-3627

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number20111783
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number20111783
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: