Healthcare Provider Details

I. General information

NPI: 1538503578
Provider Name (Legal Business Name): MELINDA HUBER HENSLEY CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2013
Last Update Date: 01/24/2023
Certification Date: 01/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3701 12TH ST N SUITE 202
SAINT CLOUD MN
56303-2255
US

IV. Provider business mailing address

14700 28TH AVE N STE 20
PLYMOUTH MN
55447-4876
US

V. Phone/Fax

Practice location:
  • Phone: 320-258-3090
  • Fax: 320-258-3095
Mailing address:
  • Phone: 320-258-3090
  • Fax: 320-258-3095

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 167920-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: