Basic Information
| Provider Information | |||||||||
| NPI: | 1215344825 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | TIBBETTS | ||||||||
| FirstName: | DANELLE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | RN, CNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6500 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554264702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529933246 | ||||||||
| FaxNumber: | 9529933010 | ||||||||
| Practice Location | |||||||||
| Address1: | 6500 EXCELSIOR BLVD | ||||||||
| Address2: | |||||||||
| City: | ST LOUIS PARK | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554264702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9529933246 | ||||||||
| FaxNumber: | 9529933010 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/15/2014 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | R189644-6 | MN | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | CNP2925 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.