Healthcare Provider Details

I. General information

NPI: 1407815145
Provider Name (Legal Business Name): ANNE-CECILE N MALLE-BARLOW CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 03/25/2020
Certification Date: 03/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

2545 CHICAGO AVE SUITE 311
MINNEAPOLIS MN
55404-4522
US

V. Phone/Fax

Practice location:
  • Phone: 952-992-5624
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 128830-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: