Provider Demographics
NPI:1760460836
Name:BLY, THERESA ROSE (APRN, CNP)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:ROSE
Last Name:BLY
Suffix:
Gender:F
Credentials:APRN, CNP
Other - Prefix:
Other - First Name:THERES
Other - Middle Name:ROSE
Other - Last Name:DESLAURIERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:300 S BRUCE ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-1934
Mailing Address - Country:US
Mailing Address - Phone:507-537-9007
Mailing Address - Fax:507-537-2720
Practice Address - Street 1:300 S BRUCE ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-1934
Practice Address - Country:US
Practice Address - Phone:507-537-9007
Practice Address - Fax:507-537-2720
Is Sole Proprietor?:No
Enumeration Date:2006-01-09
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0742363LF0000X
MNR 088633 4163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN816610200Medicaid
MN500003179Medicare PIN
MN816610200Medicaid
MN500001047Medicare PIN