Provider Demographics
NPI:1962425082
Name:MOLINE, MARISA D (APRN, CNP, CBIS)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:D
Last Name:MOLINE
Suffix:
Gender:F
Credentials:APRN, CNP, CBIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 HIGHWAY 25 N
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:MN
Mailing Address - Zip Code:55313-1930
Mailing Address - Country:US
Mailing Address - Phone:763-682-1313
Mailing Address - Fax:763-581-9090
Practice Address - Street 1:1700 HIGHWAY 25 N
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:MN
Practice Address - Zip Code:55313-1930
Practice Address - Country:US
Practice Address - Phone:763-682-1313
Practice Address - Fax:763-581-9090
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP1645363L00000X
MNR 146976-3363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN255489500Medicaid
MN500003357Medicare ID - Type Unspecified
MN255489500Medicaid
MNP00312441Medicare ID - Type UnspecifiedRAILROAD