Theresa Rose Bly, APRN, CNP
Individual provider Active NPI Family Nurse Practitioner · Marshall, MN
NPI 1760460836 · NPPES record last updated Mar 9, 2015
Key facts
- NPI
- 1760460836
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Family Nurse Practitioner 363LF0000X
- License
- 0742 (MN)
- Practice address
- 300 S Bruce St
Marshall, MN 56258-1934 - Phone
- (507) 537-9007
- Fax
- (507) 537-2720
- NPI assigned
- Jan 9, 2006
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 2
Medicare Care Compare profile
- Specialty
- Nurse Practitioner
- Education
- Other, 1999
- Medicare assignment
- Accepts the Medicare-approved amount as payment in full
- Group practices
- Park Nicollet Clinic
Practice addresses (Care Compare)
3800 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone (952) 993-3123
3850 Park Nicollet Blvd
St Louis Park, MN 55416-2527
Phone (952) 993-3123
5320 Hyland Greens Dr
Bloomington, MN 55437-3934
Phone (952) 993-2400
Medicare participation
- Medicare fee-for-service enrollment
- Enrolled in MN
- Eligible to order & refer
- Part B services: Yes · DME: Yes · Home health: Yes · Power mobility devices: Yes · Hospice: No
Medicare enrollment records
| Enrollment ID | State | Provider type | PAC ID | Details |
|---|---|---|---|---|
| I20050531000239 | MN | Practitioner - Nurse Practitioner | 7416999594 | Reassigns benefits to 1 organization |
National Provider Directory
- Medicare enrollment (NPD)
- Yes
- Credentials
- Certified Nurse Practitioner, Nurse Practitioner
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 739 | MN | MD | Marriage & Family Therapist |
| R 088633 4 | MN | MD | Registered Nurse |
| 0742 | MN | MD | Family Nurse Practitioner |
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Affordable Medical Care LLC | Family | Past | Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Family Nurse Practitioner | 363LF0000X | 0742 | MN | Yes |
| Registered Nurse | 163W00000X | R 088633 4 | MN |
Addresses
Primary practice location
300 S Bruce St
Marshall, MN 56258-1934
Mailing address
300 S Bruce St
Marshall, MN 56258-1934
Phone (507) 537-9007
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 816610200 | Medicaid | MN |
Other names
- Theres Rose Deslauriers
Other providers in Marshall, MN
- Christina Blomme
- Courtney June Blomme
- Kristin R Blomme
- Martha Alicia Blomme
- Sonia Jo Bly
- Brian David Boersma
- Riley May Boese
- Kylie Linden Bossuyt
- Julijana Botic
- Jacob Bottelberghe
All providers in Marshall, MN · Family Nurse Practitioner in Minnesota
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Mar 9, 2015. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- Medicare Fee-For-Service Public Provider Enrollment (CMS/PECOS): enrollments, PAC IDs and benefit reassignments.
- Order and Referring (CMS).
- Medicare Care Compare provider data (CMS): clinician profile, group practices, facility affiliations, MIPS scores and star ratings.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.