=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528502556
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TERESA BEKKALA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2016
-----------------------------------------------------
Last Update Date | 12/09/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14001 RIDGEDALE DR STE 100
-----------------------------------------------------
City | MINNETONKA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55305-1781
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-473-0211
-----------------------------------------------------
Fax | 952-473-7908
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1960 SHENANDOAH CT UNIT B
-----------------------------------------------------
City | PLYMOUTH
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55447-6419
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-226-5670
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | CNP 4828
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------