Provider Demographics
NPI:1790762656
Name:WHITBECK, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:WHITBECK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 FRANCE AVE S STE 1100
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-5936
Mailing Address - Country:US
Mailing Address - Phone:763-545-7545
Mailing Address - Fax:952-929-2067
Practice Address - Street 1:7600 FRANCE AVE S STE 1100
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435
Practice Address - Country:US
Practice Address - Phone:763-545-7545
Practice Address - Fax:952-929-2067
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2018-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0724807363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology