Provider Demographics
NPI:1992799589
Name:KIEBEL, CANDACE MARY (MSN)
Entity type:Individual
Prefix:
First Name:CANDACE
Middle Name:MARY
Last Name:KIEBEL
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39744 HIGHWAY 58 BLVD
Mailing Address - Street 2:
Mailing Address - City:GOODHUE
Mailing Address - State:MN
Mailing Address - Zip Code:55027-8203
Mailing Address - Country:US
Mailing Address - Phone:612-360-4450
Mailing Address - Fax:
Practice Address - Street 1:3601 MINNESOTA DR
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-5281
Practice Address - Country:US
Practice Address - Phone:763-296-1343
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2330363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
50002874Medicare ID - Type Unspecified
Q00931Medicare UPIN