Provider Demographics
NPI:1255332029
Name:ERICKSON, MARY M (RNC PNP MPH)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:ERICKSON
Suffix:
Gender:F
Credentials:RNC PNP MPH
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Mailing Address - Street 1:CHILDREN'S HEALTH CARE
Mailing Address - Street 2:2910 CENTRE POINTE DRIVE 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:CHILDREN'S PRIMARY CLINIC - STPL
Practice Address - Street 2:347 NORTH SMITH AVENUE
Practice Address - City:ST PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102
Practice Address - Country:US
Practice Address - Phone:651-220-6789
Practice Address - Fax:651-220-6807
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-03
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MNR073480-0363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics