Healthcare Provider Details

I. General information

NPI: 1942649181
Provider Name (Legal Business Name): THERESA M HAVALAD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

870 GRAND AVE
SAINT PAUL MN
55105-3291
US

IV. Provider business mailing address

1690 UNIVERSITY AVE W STE 370
SAINT PAUL MN
55104-3723
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-5650
  • Fax: 651-326-5671
Mailing address:
  • Phone: 651-232-5321
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number041-374413
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5534
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: