=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326225731
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CAROL JEAN AVERBECK RN, CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/28/2008
-----------------------------------------------------
Last Update Date | 01/28/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1164 30TH ST SE
-----------------------------------------------------
City | BUFFALO
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55313-5335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 763-682-6716
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12755 HIGHWAY 55 MN009-S130
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55441-3837
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 800-896-8936
-----------------------------------------------------
Fax | 888-866-3209
-----------------------------------------------------
=====================================================
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 | R081347-5
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------