Healthcare Provider Details

I. General information

NPI: 1235260993
Provider Name (Legal Business Name): PRAIRIE ST. JOHNS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11610 WAYZATA BLVD
MINNETONKA MN
55305-2009
US

IV. Provider business mailing address

110 W GRANT ST APT 9J
MINNEAPOLIS MN
55403-2311
US

V. Phone/Fax

Practice location:
  • Phone: 952-230-9180
  • Fax:
Mailing address:
  • Phone: 612-940-1546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282NC2000X
TaxonomyChildren's Hospital
License Number14993
License Number StateMN

VIII. Authorized Official

Name: MS. GINA KINNAMON
Title or Position: EXECUTIVE ASSISTANT
Credential:
Phone: 701-476-7208