MEDICARE: KARIN E DETIENNE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	L447456	MN

General Provider Information

NPI Number	:	1053269951
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KARIN E DETIENNE

Provider Business Mailing Address
First Line	:	23065 W RIVER RD
Second Line	:
City	:	GRANTSBURG
State	:	WI
Zip	:	54840-8303
Country	:	US
Telephone Number	:	715-431-0955
Fax Number	:

Provider Business Practice Location Address
First Line	:	3100 KENNARD ST
Second Line	:
City	:	MAPLEWOOD
State	:	MN
Zip	:	55109-5465
Country	:	US
Telephone Number	:	651-225-5447
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/18/2026
Last Update Date	:	03/18/2026

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Directions to “ KARIN E DETIENNE ” Practice Location

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