Provider Demographics
NPI:1689634677
Name:ELDER, MARY ANNE (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ANNE
Last Name:ELDER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 NICOLLET MALL
Mailing Address - Street 2:SUITE 1149
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55402-2606
Mailing Address - Country:US
Mailing Address - Phone:612-338-3333
Mailing Address - Fax:612-349-3838
Practice Address - Street 1:825 NICOLLET MALL
Practice Address - Street 2:SUITE 1149
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55402-2606
Practice Address - Country:US
Practice Address - Phone:612-338-3333
Practice Address - Fax:612-349-3838
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2010-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1176072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN50017800Medicaid
MNQ27416Medicare UPIN
MN50017800Medicaid