Basic Information
| Provider Information | |||||||||
| NPI: | 1003150194 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLIPP | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | SUSAN | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | CPNP-AC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 HARRIET AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554083729 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7735124511 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2450 RIVERSIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554541450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6123653100 | ||||||||
| FaxNumber: | 6123653110 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/15/2012 | ||||||||
| LastUpdateDate: | 11/15/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0222X | 2036438 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics, Critical Care |
No ID Information.