Healthcare Provider Details

I. General information

NPI: 1679874887
Provider Name (Legal Business Name): DESTINY DAY HAGEN CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2010
Last Update Date: 03/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6500 EXCELSIOR BLVD
ST LOUIS PARK MN
55426-4702
US

IV. Provider business mailing address

PO BOX 650
MINNEAPOLIS MN
55440-0650
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-2750
  • Fax: 952-993-0300
Mailing address:
  • Phone: 952-993-2750
  • Fax: 952-993-0300

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR 171531-0
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: