Healthcare Provider Details

I. General information

NPI: 1912069519
Provider Name (Legal Business Name): NORTHERN LIGHTS PEDIATRIC & ADOLESCENT MEDICINE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2006
Last Update Date: 05/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3555 WILLOW LAKE BLVD. SUITE 140
VADNAIS HEIGHTS MN
55110-4462
US

IV. Provider business mailing address

3555 WILLOW LAKE BLVD. SUITE 140
VADNAIS HEIGHTS MN
55110-4462
US

V. Phone/Fax

Practice location:
  • Phone: 651-251-5280
  • Fax: 651-251-5282
Mailing address:
  • Phone: 651-251-5280
  • Fax: 651-251-5282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: WENDY MARIAN NELMS MCCABE
Title or Position: PARTNER
Credential: M.D.
Phone: 651-251-5280