Basic Information
| Provider Information | |||||||||
| NPI: | 1023117637 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | O'BRIEN | ||||||||
| FirstName: | MICHELE | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | CNS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6545 FRANCE AVE S | ||||||||
| Address2: | SUITE 210 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352131 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529282900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6545 FRANCE AVE S | ||||||||
| Address2: | STE 210 | ||||||||
| City: | EDINA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554352281 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529282900 | ||||||||
| FaxNumber: | 9529282944 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 11/17/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364SA2200X | R1215438 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 196693000 | 05 | MN | MEDICAID |