Healthcare Provider Details

I. General information

NPI: 1669615613
Provider Name (Legal Business Name): KARLA JEAN NOCKLEBY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 JACKSON ST
SAINT PAUL MN
55101-2502
US

IV. Provider business mailing address

8170 33RD AVE S MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 651-254-3456
  • Fax: 651-254-9673
Mailing address:
  • Phone: 651-254-3456
  • Fax: 651-254-9673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number51969
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number51969
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number53121
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number53121
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: