Healthcare Provider Details

I. General information

NPI: 1245625664
Provider Name (Legal Business Name): CATHERINE MARY CARLSON APRN, CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 04/02/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1935 COUNTY ROAD B2 W SUITE 100
ROSEVILLE MN
55113-2729
US

IV. Provider business mailing address

1935 COUNTY ROAD B2 W SUITE 100
ROSEVILLE MN
55113-2729
US

V. Phone/Fax

Practice location:
  • Phone: 651-636-4155
  • Fax:
Mailing address:
  • Phone: 651-636-4155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberCNP 3804
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: