Basic Information
Provider Information | |||||||||
NPI: | 1144779067 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MCNEIL | ||||||||
FirstName: | MYRTO | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CRNP, DNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | TELISMA | ||||||||
OtherFirstName: | MYRTO | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | DNP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 550 MAIN STREET, SUITE 250 | ||||||||
Address2: |   | ||||||||
City: | NEW BRIGHTON | ||||||||
State: | MN | ||||||||
PostalCode: | 55112 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6123267575 | ||||||||
FaxNumber: | 6124542430 | ||||||||
Practice Location | |||||||||
Address1: | 135 COLORADO STREET EAST | ||||||||
Address2: |   | ||||||||
City: | ST. PAUL | ||||||||
State: | MN | ||||||||
PostalCode: | 55107 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6514897740 | ||||||||
FaxNumber: | 6514896458 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 10/04/2016 | ||||||||
LastUpdateDate: | 12/03/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/03/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0808X | SP016614 | PA | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 7418 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.