Provider Demographics
NPI:1447229026
Name:KOPISCHKE, MARYNNE L (NP)
Entity type:Individual
Prefix:
First Name:MARYNNE
Middle Name:L
Last Name:KOPISCHKE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:6545 FRANCE AVE S
Mailing Address - Street 2:STE 210
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2281
Mailing Address - Country:US
Mailing Address - Phone:952-928-2900
Mailing Address - Fax:952-928-2944
Practice Address - Street 1:6545 FRANCE AVE S
Practice Address - Street 2:STE 210
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2281
Practice Address - Country:US
Practice Address - Phone:952-928-2900
Practice Address - Fax:952-928-2944
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR113270-2363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43841400Medicaid
MN780824100Medicaid
MN1007082OtherPREFERREDONE
MT4305471Medicaid
MN851169OtherAMERICA'S PPO
MN8T414KOOtherBLUECROSS BLUE SHIELD MN
MN0410560OtherMEDICA
MN151560OtherUCARE MN
MNHP33242OtherHEALTHPARTNERS
MN851169OtherAMERICA'S PPO
MN8T414KOOtherBLUECROSS BLUE SHIELD MN
MT4305471Medicaid