Provider Demographics
NPI:1073690012
Name:MACKENBURG MOHN, MARY D (NP)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:D
Last Name:MACKENBURG MOHN
Suffix:
Gender:F
Credentials:NP
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Mailing Address - Street 1:2910 CENTRE POINTE DRIVE
Mailing Address - Street 2:35121A CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2327
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1450
Practice Address - Country:US
Practice Address - Phone:126-726-0006
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MNR0933245363L00000X, 363LP0200X, 363LP2300X
CO0991736363L00000X, 363LA2100X
MN2472363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN878708200Medicaid