Provider Demographics
NPI:1629130778
Name:KNUTSON, MARY BETH (RN, MS, FCP)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:BETH
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:RN, MS, FCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5512 COUNTY 3
Mailing Address - Street 2:
Mailing Address - City:HOKAH
Mailing Address - State:MN
Mailing Address - Zip Code:55941-8732
Mailing Address - Country:US
Mailing Address - Phone:507-724-2363
Mailing Address - Fax:
Practice Address - Street 1:5512 COUNTY 3
Practice Address - Street 2:
Practice Address - City:HOKAH
Practice Address - State:MN
Practice Address - Zip Code:55941-8732
Practice Address - Country:US
Practice Address - Phone:507-724-2363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR093754163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN94G42KNOtherBLUE CROSS BLUE SHIELD