Healthcare Provider Details

I. General information

NPI: 1427341247
Provider Name (Legal Business Name): KIMBERLY A WALSH NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2011
Last Update Date: 02/04/2021
Certification Date: 02/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3931 LOUISIANA AVE S
ST LOUIS PARK MN
55426-5000
US

IV. Provider business mailing address

3931 LOUISIANA AVE S
ST LOUIS PARK MN
55426-5000
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-3248
  • Fax:
Mailing address:
  • Phone: 952-993-3248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR158402-0
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberCNP2078
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: