Provider Demographics
NPI:1407819402
Name:CARLEEN, CONNIE MARIE (MD)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:CARLEEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 43
Mailing Address - Street 2:MR 10809
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55440-0043
Mailing Address - Country:US
Mailing Address - Phone:612-262-4813
Mailing Address - Fax:612-262-4194
Practice Address - Street 1:4194 LEXINGTON AVE N
Practice Address - Street 2:
Practice Address - City:SHOREVIEW
Practice Address - State:MN
Practice Address - Zip Code:55126-6106
Practice Address - Country:US
Practice Address - Phone:651-483-5461
Practice Address - Fax:651-483-2155
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2020-11-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN41589207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H10753Medicare UPIN