Healthcare Provider Details

I. General information

NPI: 1992734826
Provider Name (Legal Business Name): MARY WATZKA LAGAARD RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2006
Last Update Date: 07/05/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9701 DATA PARK MN006-W600
MINNETONKA MN
55343-9026
US

IV. Provider business mailing address

600 313TH LN NE
CAMBRIDGE MN
55008-6869
US

V. Phone/Fax

Practice location:
  • Phone: 800-896-8936
  • Fax: 888-866-3209
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR093850-9
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: