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General NPI Number Information
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NPI Number | 1790490241
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Entity Type | Individual
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Provider Name | ALEMU KASSA RETA
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Gender | Male
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Dates
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Enumeration Date | 01/19/2023
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Last Update Date | 01/19/2023
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Provider Practice Location Address
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Address Line | 15251 PLEASANT VALLEY RD
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City | CENTER CITY
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State | MN
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Zip | 55012-9640
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Country | US
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Telephone | 651-213-4984
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Fax |
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Provider Business Mailing Address
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Address Line | 3318 138TH AVE NW
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City | ANDOVER
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State | MN
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Zip | 55304-7508
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Country | US
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Telephone | 612-978-2232
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 9751
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License Number State | MN
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