MEDICARE: JUSTINE FOSLE FNP-C

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	363L00000X	Nurse Practitioner	11803	MN
2	163W00000X	Registered Nurse	2358271	MN

General Provider Information

NPI Number	:	1104661818
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUSTINE FOSLE FNP-C

Provider Business Mailing Address
First Line	:	5115 EXCELSIOR BLVD STE 712
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55416-2906
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2820 INGLEWOOD AVE S
Second Line	:
City	:	ST LOUIS PARK
State	:	MN
Zip	:	55416-4112
Country	:	US
Telephone Number	:	914-589-5503
Fax Number	:

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

Provider Enumeration Date	:	06/26/2024
Last Update Date	:	07/23/2024

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