Provider Demographics
NPI:1629400163
Name:THINER, CARLY (NP-C)
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:THINER
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 SAINT FRANCIS AVE
Mailing Address - Street 2:
Mailing Address - City:SHAKOPEE
Mailing Address - State:MN
Mailing Address - Zip Code:55379-3374
Mailing Address - Country:US
Mailing Address - Phone:952-993-7750
Mailing Address - Fax:
Practice Address - Street 1:20795 KEOKUK AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-6004
Practice Address - Country:US
Practice Address - Phone:524-281-0309
Practice Address - Fax:952-428-0399
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3091363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health