Provider Demographics
NPI:1932174828
Name:SCHALLA LESIAK, KATY MARIE (CPNP)
Entity Type:Individual
Prefix:
First Name:KATY
Middle Name:MARIE
Last Name:SCHALLA LESIAK
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:KATY
Other - Middle Name:MARIE SCHALLA
Other - Last Name:LESIAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2910 CENTRE POINTE DR
Mailing Address - Street 2:35-121A CHILDRENS HEALTH CARE
Mailing Address - City:ROSEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55113
Mailing Address - Country:US
Mailing Address - Phone:651-855-2109
Mailing Address - Fax:651-855-2310
Practice Address - Street 1:2525 CHICAGO AVE S
Practice Address - Street 2:CHILDRENS PRIMARY CLINIC MPLS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404
Practice Address - Country:US
Practice Address - Phone:612-813-6107
Practice Address - Fax:612-813-7473
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1481301363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
P18913Medicare UPIN