Provider Demographics
NPI:1447648506
Name:TARGET CLINIC
Entity type:Organization
Organization Name:TARGET CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FNP
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTY
Authorized Official - Middle Name:
Authorized Official - Last Name:BERRYHILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:612-327-5134
Mailing Address - Street 1:1300 UNIVERSITY AVE W
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55104-4103
Mailing Address - Country:US
Mailing Address - Phone:651-642-1146
Mailing Address - Fax:
Practice Address - Street 1:1300 UNIVERSITY AVE W
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55104-4103
Practice Address - Country:US
Practice Address - Phone:651-642-1146
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 158470 3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty