1851478895 NPI number — KRISTIN M DETTMER APRN

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1851478895 NPI number — KRISTIN M DETTMER APRN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DETTMER
Provider First Name:
KRISTIN
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN
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:
1851478895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2910 CENTRE POINTE DR 35-121A
Provider Second Line Business Mailing Address:
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:
345 NORTH SMITH AVE
Provider Second Line Business Practice Location Address:
CHILDRENS HOSPITALS AND CLINICS OF MINNESOTA
Provider Business Practice Location Address City Name:
ST PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-220-6914
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/01/2006

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: 363LP0200X , with the licence number:  357 , 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: 797603800 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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