Provider Demographics
NPI:1255767877
Name:CARLSON, BECKY MARIE (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:BECKY
Middle Name:MARIE
Last Name:CARLSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:BECKY
Other - Middle Name:MARIE
Other - Last Name:HENRICHS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:REGISTERED NURSE
Mailing Address - Street 1:545 S 2ND ST
Mailing Address - Street 2:UNIT 209
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55401-2385
Mailing Address - Country:US
Mailing Address - Phone:612-963-2514
Mailing Address - Fax:
Practice Address - Street 1:420 DELAWARE ST SE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455-0341
Practice Address - Country:US
Practice Address - Phone:612-626-6736
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-16
Last Update Date:2013-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR184226-7163W00000X
WI162597-30163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse