Provider Demographics
NPI:1912075573
Name:SIMON, KATHRINE LYNNE (CNM MS)
Entity Type:Individual
Prefix:
First Name:KATHRINE
Middle Name:LYNNE
Last Name:SIMON
Suffix:
Gender:F
Credentials:CNM MS
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2925 CHICAGO AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55407-1321
Mailing Address - Country:US
Mailing Address - Phone:612-262-9000
Mailing Address - Fax:
Practice Address - Street 1:7920 OLD CEDAR AVE S
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-1207
Practice Address - Country:US
Practice Address - Phone:952-428-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-01
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN173367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN017097600Medicaid