Healthcare Provider Details

I. General information

NPI: 1417482290
Provider Name (Legal Business Name): LINDSEY KOTERBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 PARK NICOLLET BLVD
ST LOUIS PARK MN
55416-2527
US

IV. Provider business mailing address

8038 SPRING LAKE LN
SHAKOPEE MN
55379-8529
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-1000
  • Fax:
Mailing address:
  • Phone: 952-356-6370
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5132
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5132
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: