Provider Demographics
NPI:1336490929
Name:FELICETTA, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:FELICETTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3358 LINCOLN ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1454
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8990 SPRINGBROOK DR NW
Practice Address - Street 2:#250
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:764-360-5348
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-09-24
Last Update Date:2012-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN091718367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered