Provider Demographics
NPI:1982643524
Name:O'FALLON, MARY THERESE (CNRN, CNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:THERESE
Last Name:O'FALLON
Suffix:
Gender:F
Credentials:CNRN, CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 CENTURY AVE SE
Mailing Address - Street 2:
Mailing Address - City:HUTCHINSON
Mailing Address - State:MN
Mailing Address - Zip Code:55350-3108
Mailing Address - Country:US
Mailing Address - Phone:320-587-2020
Mailing Address - Fax:320-234-3295
Practice Address - Street 1:3 CENTURY AVE SE
Practice Address - Street 2:
Practice Address - City:HUTCHINSON
Practice Address - State:MN
Practice Address - Zip Code:55350-3108
Practice Address - Country:US
Practice Address - Phone:320-587-2020
Practice Address - Fax:320-234-3295
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0761721363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNS87927Medicare UPIN