Healthcare Provider Details

I. General information

NPI: 1700399649
Provider Name (Legal Business Name): JOAN MARIE KOTILA APRN CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2017
Last Update Date: 11/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 COUNTY ROAD 120
SAINT CLOUD MN
56303-4872
US

IV. Provider business mailing address

CENTRACARE CLINIC ST CLOUD MEDICAL GROUP NORTHWEST 251 COUNTY ROAD 120
ST CLOUD MN
56303-4872
US

V. Phone/Fax

Practice location:
  • Phone: 320-202-8949
  • Fax: 320-257-1733
Mailing address:
  • Phone: 320-202-8949
  • Fax: 320-257-1733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2019769
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5273
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: