Healthcare Provider Details

I. General information

NPI: 1760824874
Provider Name (Legal Business Name): KRISTINA RAE CARLSON RN, MSN, NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2013
Last Update Date: 08/25/2020
Certification Date: 08/25/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

625 N. JACKSON AVENUE
SPRINGFIELD MN
56087
US

IV. Provider business mailing address

625 N. JACKSON AVENUE
SPRINGFIELD MN
56087
US

V. Phone/Fax

Practice location:
  • Phone: 877-412-7575
  • Fax:
Mailing address:
  • Phone: 877-412-7575
  • Fax: 507-723-6447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1502
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: