=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205689239
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELLEN VIRGINIA KEARNEY
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2024
-----------------------------------------------------
Last Update Date | 08/12/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3930 NORTHWOODS DR
-----------------------------------------------------
City | ARDEN HILLS
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55112-6963
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-853-8800
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 668 CHEROKEE AVE
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55107-2509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-270-8956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 11182
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------