=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922034933
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GRETCHEN A MOEN DNP, APRN, CPNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/23/2006
-----------------------------------------------------
Last Update Date | 07/16/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1057 GRAND AVE FL 2
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55105-3002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-384-1736
-----------------------------------------------------
Fax | 651-666-1507
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4734 WESTMINSTER CIR
-----------------------------------------------------
City | EAGAN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55122-2756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-456-0127
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2080P0006X
-----------------------------------------------------
Taxonomy Name | Developmental - Behavioral Pediatrics Physician
-----------------------------------------------------
License Number | 2574
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0200X
-----------------------------------------------------
Taxonomy Name | Pediatric Nurse Practitioner
-----------------------------------------------------
License Number | 2574
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------