Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 363L00000X | Nurse Practitioner | R 197063-4 | MN |
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | CNP 4630 | MN |
NPI | 1013364199 |
---|---|
Provider Name | Haley Carlock |
First Address | Minneapolis, MN 55416-4527 |
Second Address | St Louis Park, MN 55426-1099 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 19/05/2016 |
Last Update Date | 26/04/2017 |