Provider Demographics
NPI:1790988913
Name:NEWBY-LOVELACE, JEAN RAE
Entity Type:Individual
Prefix:
First Name:JEAN
Middle Name:RAE
Last Name:NEWBY-LOVELACE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:NEWBY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:400 STINSON BLVD
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2614
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2450 RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55454-2116
Practice Address - Country:US
Practice Address - Phone:612-672-6000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1760-029133V00000X
MN7007363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered