Healthcare Provider Details

I. General information

NPI: 1831931716
Provider Name (Legal Business Name): MARISA EVA PAULE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 06/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD FL 5
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

8143 VINCENT AVE S
BLOOMINGTON MN
55431-1238
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-0377
  • Fax: 952-993-5397
Mailing address:
  • Phone: 952-457-0567
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WW0101X
TaxonomyAmbulatory Women's Health Care Registered Nurse
License Number2497341
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: