1023074655 NPI number — GRETCHEN L HANSON CNNP

Table of content: GRETCHEN L HANSON CNNP (NPI 1023074655)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023074655 NPI number — GRETCHEN L HANSON CNNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
HANSON
Provider First Name:
GRETCHEN
Provider Middle Name:
L
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023074655
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/20/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2910 CENTRE POINTE DRIVE
Provider Second Line Business Mailing Address:
35-121A CHILDRENS HEALTH CARE
Provider Business Mailing Address City Name:
ROSEVILLE
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55113
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
651-855-2327
Provider Business Mailing Address Fax Number:
651-855-2310

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1575 BEAM AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MAPLEWOOD
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55109-1126
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-232-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/22/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LN0005X , with the licence number:  R1402513 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LN0000X , with the licence number: R1402513 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 305435700 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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