=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982761763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARCEA EDITH KJERVIK R.N.,M.S.,C.S.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2007
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1919 UNIVERSITY AVE W SUITE 200
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-3453
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-266-7999
-----------------------------------------------------
Fax | 651-266-7850
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5817 CREEK VALLEY RD
-----------------------------------------------------
City | EDINA
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55439-1211
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 952-941-8484
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R0938347
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------