Provider Demographics
NPI:1043669682
Name:BEHNKE, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:BEHNKE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 FREEMAN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT PETER
Mailing Address - State:MN
Mailing Address - Zip Code:56082-3504
Mailing Address - Country:US
Mailing Address - Phone:507-985-2832
Mailing Address - Fax:
Practice Address - Street 1:100 FREEMAN DR
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082
Practice Address - Country:US
Practice Address - Phone:507-985-2832
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-04
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4544363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health