Provider Demographics
NPI:1144284274
Name:CARLSON, MARY BESS (ANP, GNP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:BESS
Last Name:CARLSON
Suffix:
Gender:F
Credentials:ANP, GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7335 110TH ST E
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-4832
Mailing Address - Country:US
Mailing Address - Phone:507-581-0621
Mailing Address - Fax:
Practice Address - Street 1:7335 110TH ST E
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-4832
Practice Address - Country:US
Practice Address - Phone:507-581-0621
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-14
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR098201-8363LG0600X, 363LA2200X
MN1325363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN103242900Medicaid