Healthcare Provider Details

I. General information

NPI: 1255683280
Provider Name (Legal Business Name): SUSAN MARIE KOHN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2012
Last Update Date: 10/15/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16501 TEMPLE DR N
MINNETONKA MN
55345-3435
US

IV. Provider business mailing address

16501 TEMPLE DR N
MINNETONKA MN
55345-3435
US

V. Phone/Fax

Practice location:
  • Phone: 952-465-6027
  • Fax:
Mailing address:
  • Phone: 952-465-6027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR120636-6
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: