Provider Demographics
NPI:1992960819
Name:SORENSEN-TANENBAUM, KRISTIN COLE (NP-C)
Entity type:Individual
Prefix:
First Name:KRISTIN
Middle Name:COLE
Last Name:SORENSEN-TANENBAUM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:MARY
Other - Last Name:SORENSEN-TANENBAUM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP-C, PMH-NP
Mailing Address - Street 1:3125 WILLIVAN WOODS
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-8661
Mailing Address - Country:US
Mailing Address - Phone:301-741-6101
Mailing Address - Fax:
Practice Address - Street 1:413 SE 13TH ST
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-0015
Practice Address - Country:US
Practice Address - Phone:218-999-9908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-21
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN5112363LP0808X
MDR160645363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily