Healthcare Provider Details

I. General information

NPI: 1982883369
Provider Name (Legal Business Name): DIANE SODERHOLM CLAVEL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2007
Last Update Date: 11/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2550 UNIVERSITY AVE W SUITE 189S
ST. PAUL MN
55114-5802
US

IV. Provider business mailing address

2550 UNIVERSITY AVE W SUITE 189S
ST. PAUL MN
55114-5802
US

V. Phone/Fax

Practice location:
  • Phone: 651-332-7470
  • Fax: 651-332-7490
Mailing address:
  • Phone: 651-332-7470
  • Fax: 651-332-7490

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberR098281-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: