Provider Demographics
NPI:1063599892
Name:THEISEN, CONNIE
Entity type:Individual
Prefix:DR
First Name:CONNIE
Middle Name:
Last Name:THEISEN
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 1:12748 WALTER DR
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-5822
Mailing Address - Country:US
Mailing Address - Phone:763-360-2405
Mailing Address - Fax:
Practice Address - Street 1:9479 GARLAND AVE
Practice Address - Street 2:
Practice Address - City:MAPLE GROVE
Practice Address - State:MN
Practice Address - Zip Code:55311-5480
Practice Address - Country:US
Practice Address - Phone:763-494-8787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNDC4091111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN078K2HEOtherBCBS MN
MN065473600OtherMN STATE AID
MN112377OtherHEALTH PARTNERS
MN44-00217OtherMEDICA
MN065473600OtherMN STATE AID