Provider Demographics
NPI:1114988664
Name:TAIVAL, LYNN M (CPNP)
Entity Type:Individual
Prefix:
First Name:LYNN
Middle Name:M
Last Name:TAIVAL
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 CENTRE POINT DRIVE
Mailing Address - Street 2:35-121A
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 1:347 NORTH SMITH AVENUE
Practice Address - Street 2:CHILDRENS SPECIALTY CLINIC NICU FOLLOW UP CLINIC
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-8063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2012-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1371262363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN221927100Medicaid
MN221927100Medicaid
P87616Medicare UPIN