Provider Demographics
NPI:1225005739
Name:CERONSKY, CAROLYN M (NP)
Entity Type:Individual
Prefix:
First Name:CAROLYN
Middle Name:M
Last Name:CERONSKY
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LYN
Other - Middle Name:
Other - Last Name:CERONSKY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1900 STOWE AVE
Mailing Address - Street 2:
Mailing Address - City:ARDEN HILLS
Mailing Address - State:MN
Mailing Address - Zip Code:55112-7826
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1512
Practice Address - Country:US
Practice Address - Phone:612-672-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-02
Last Update Date:2009-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR076160-8363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ15813Medicare UPIN