Basic Information
Provider Information | |||||||||
NPI: | 1649685546 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | AILABOUNI | ||||||||
FirstName: | KATIE | ||||||||
MiddleName: | JO | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | RN, CNP | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | RUDNITSKI | ||||||||
OtherFirstName: | KATIE | ||||||||
OtherMiddleName: | JO | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 2925 CHICAGO AVE | ||||||||
Address2: |   | ||||||||
City: | MINNEAPOLIS | ||||||||
State: | MN | ||||||||
PostalCode: | 554071321 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6122625000 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 14000 NICOLLET AVE STE 100 | ||||||||
Address2: |   | ||||||||
City: | BURNSVILLE | ||||||||
State: | MN | ||||||||
PostalCode: | 553375793 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9524280200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2014 | ||||||||
LastUpdateDate: | 03/11/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 195420-7 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LF0000X | 195420-7 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.