Provider Demographics
NPI:1861703548
Name:NEISEN, MARY BETH (FNP-BC)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:NEISEN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9766 FALLON AVENUE SUITE 102
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MN
Mailing Address - Zip Code:55362-4589
Mailing Address - Country:US
Mailing Address - Phone:763-272-1500
Mailing Address - Fax:763-272-1503
Practice Address - Street 1:9766 FALLON AVE NE STE 102
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:MN
Practice Address - Zip Code:55362-4589
Practice Address - Country:US
Practice Address - Phone:763-272-1500
Practice Address - Fax:763-272-1503
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR89486-3363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily