Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LN0000X | Nurse Practitioner - Neonatal | R1602591 | MN |
NPI | 1003891144 |
---|---|
Provider Name | Tracy Suzanne Cousin |
First Address | St Cloud, MN 56303 |
Second Address | St Cloud, MN 56303 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 13/12/2005 |
Last Update Date | 08/07/2007 |