Healthcare Provider Details

I. General information

NPI: 1205223989
Provider Name (Legal Business Name): ANDREA BERUBE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2015
Last Update Date: 12/29/2024
Certification Date: 12/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 DIVISION ST S
NORTHFIELD MN
55057-2087
US

IV. Provider business mailing address

2651 OAK LAWN DR
NORTHFIELD MN
55057-3443
US

V. Phone/Fax

Practice location:
  • Phone: 612-616-7731
  • Fax:
Mailing address:
  • Phone: 612-616-7731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA 1731
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number10374
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: