Healthcare Provider Details

I. General information

NPI: 1295050177
Provider Name (Legal Business Name): CODI LYN WARNECKE RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2010
Last Update Date: 01/30/2023
Certification Date: 01/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4504 LAX LAKE RD
SILVER BAY MN
55614-3806
US

IV. Provider business mailing address

4504 LAX LAKE RD
SILVER BAY MN
55614-3806
US

V. Phone/Fax

Practice location:
  • Phone: 218-220-8947
  • Fax:
Mailing address:
  • Phone: 218-220-8947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR179350-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: