Provider Demographics
NPI:1578187084
Name:WAHL, MARCIA (RN)
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:
Last Name:WAHL
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 INTERLACHEN RD
Mailing Address - Street 2:
Mailing Address - City:HOPKINS
Mailing Address - State:MN
Mailing Address - Zip Code:55343-8523
Mailing Address - Country:US
Mailing Address - Phone:763-226-3620
Mailing Address - Fax:
Practice Address - Street 1:2220 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-1321
Practice Address - Country:US
Practice Address - Phone:612-341-6815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-31
Last Update Date:2020-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1238648163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health