Healthcare Provider Details

I. General information

NPI: 1104751445
Provider Name (Legal Business Name): IMANI DYRDAHL BSN, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2026
Last Update Date: 06/17/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SMITH AVE N
SAINT PAUL MN
55102-2344
US

IV. Provider business mailing address

1745 BIRMINGHAM ST
MAPLEWOOD MN
55109-4508
US

V. Phone/Fax

Practice location:
  • Phone: 612-231-6442
  • Fax:
Mailing address:
  • Phone: 612-231-6442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0102X
TaxonomyMaternal Newborn Registered Nurse
License Number231773-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: