Provider Demographics
NPI:1205894870
Name:COLLYARD-GLINSEK, CARRIE LYNN
Entity type:Individual
Prefix:DR
First Name:CARRIE
Middle Name:LYNN
Last Name:COLLYARD-GLINSEK
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 1:11044 255TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-4578
Mailing Address - Country:US
Mailing Address - Phone:763-856-2828
Mailing Address - Fax:763-633-0366
Practice Address - Street 1:19242 EVANS ST NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1076
Practice Address - Country:US
Practice Address - Phone:763-274-0377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC4090111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN52F79COOtherBCBS GROUP NUMBER
MN52F80COOtherBCBS INDIVIDUAL PROV. #
MN966407600Medicaid
MN350002464Medicare ID - Type UnspecifiedMEDICARE NUMBER
MN966407600Medicaid