Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | R1475155 | MN |
N | 363LN0005X | Nurse Practitioner - Neonatal (Critical Care) | R1475155 | MN |
NPI | 1205892833 |
---|---|
Provider Name | Carmen Renee Grande Henke |
First Address | Roseville, MN 55113 |
Second Address | St Paul, MN 55102 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 22/04/2006 |
Last Update Date | 19/12/2016 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
318656300 | (05) | MN |