Provider Demographics
NPI:1386160166
Name:CODY, KRISTINE MARY
Entity type:Individual
Prefix:
First Name:KRISTINE
Middle Name:MARY
Last Name:CODY
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 1:1611 73RD ST W
Mailing Address - Street 2:
Mailing Address - City:INVER GROVE HEIGHTS
Mailing Address - State:MN
Mailing Address - Zip Code:55077-2001
Mailing Address - Country:US
Mailing Address - Phone:320-260-9224
Mailing Address - Fax:
Practice Address - Street 1:3305 CENTRAL PARK VILLAGE DR
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55121-7707
Practice Address - Country:US
Practice Address - Phone:651-406-8860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-14
Last Update Date:2020-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5276363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily