Healthcare Provider Details

I. General information

NPI: 1548230196
Provider Name (Legal Business Name): PHYLLIS C WIENER WHCNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 LAGOON AVE
MINNEAPOLIS MN
55408-2077
US

IV. Provider business mailing address

4028 ELLIOT AVE
MINNEAPOLIS MN
55407-3147
US

V. Phone/Fax

Practice location:
  • Phone: 612-823-6300
  • Fax:
Mailing address:
  • Phone: 612-822-1548
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR1017050
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: