Healthcare Provider Details

I. General information

NPI: 1871914887
Provider Name (Legal Business Name): BROOKE HABISCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/17/2013
Last Update Date: 06/26/2023
Certification Date: 06/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 W 23RD ST
SAINT LOUIS PARK MN
55416
US

IV. Provider business mailing address

5320 W 23RD ST
SAINT LOUIS PARK MN
55416
US

V. Phone/Fax

Practice location:
  • Phone: 952-345-8770
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number6118
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: