Healthcare Provider Details

I. General information

NPI: 1629804810
Provider Name (Legal Business Name): TERESA KAY LYNNE RN, BAN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 09/12/2024
Certification Date: 09/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 N 11TH ST
MONTEVIDEO MN
56265-1629
US

IV. Provider business mailing address

814 N 11TH ST
MONTEVIDEO MN
56265-1629
US

V. Phone/Fax

Practice location:
  • Phone: 320-368-8986
  • Fax: 320-269-8929
Mailing address:
  • Phone: 320-255-6339
  • Fax: 320-269-8929

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR1110038
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: