1639232804 NPI number — NANCY MARIE CUSACK M.A.

Table of content: NANCY MARIE CUSACK M.A. (NPI 1639232804)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639232804 NPI number — NANCY MARIE CUSACK M.A.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CUSACK
Provider First Name:
NANCY
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.A.
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:
1639232804
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/05/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4023 24TH AVE S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55406-3023
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-823-6578
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
425 COON RAPIDS BLVD NW STE 200
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
COON RAPIDS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55433-2753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
763-784-3008
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2006

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: 103T00000X , with the licence number:  LP 3907 , 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: HP 37869 . This is a "HEALTH PARTNERS" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".
  • Identifier: 201945100 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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