Healthcare Provider Details

I. General information

NPI: 1285652271
Provider Name (Legal Business Name): CAROLYN KEUP WEBER RN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12755 HIGHWAY 55 MN009-S130
PLYMOUTH MN
55441-3837
US

IV. Provider business mailing address

17000 19TH AVE N
PLYMOUTH MN
55447-2739
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 NumberR0932123
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: