NPIMap

Individual provider Active NPI

Kristin Broback, NP, C

  • Family Nurse Practitioner
  • Blaine, MN
National Provider Identifier
1841776242
Registry record updated Nov 10, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Nurse PractitionerTaxonomy code 363LF0000X
License
5976 Issued in MN
Practice address
10705 Town Square Dr NE #100
Blaine, MN 55449
Phone
(763) 236-5400
NPI assigned
Jul 18, 2018
Last updated
Nov 10, 2020By the provider in NPPES
Sex
Female
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Nov 10, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Family Nurse Practitioner 363LF0000X 5976 MN Primary

Addresses

Primary practice location

10705 Town Square Dr NE #100
Blaine, MN 55449

Mailing address

10705 Town Square Dr NE Ste 100
Blaine, MN 55449-8185
Phone (163) 236-5400

Electronic endpoints 1

TypeEndpointUseAffiliation
Direct Messaging Address khall379090@excellian.direct.allina.com Direct

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MN
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20181008001707 MN Practitioner - Nurse Practitioner 8921350612 Reassigns benefits to 2 organizations

Care Compare profile

Medicare Care Compare
Specialty
Nurse Practitioner
Education
Other, 2018
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
Allina Health SystemGroup PAC ID 4587573613, shared by 89 NPIs, 3,844 clinicians

Practice addresses (Care Compare)

440 Elm St E
Annandale, MN 55302-1109
Phone (320) 682-5225

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Nurse Practitioner

State licenses

LicenseStateTypeSpecialty
5976MNMDAudiologist

Practice roles

OrganizationSpecialtyStatusNew patients
Allina Health System CurrentSince Dec 31, 2022 Accepting new patients
Allina Health System Current Accepting new patients
Allina Health System Current Accepting new patients
Allina Health System CurrentSince Oct 1, 2018 Accepting new patients
Allina Health System CurrentSince Oct 1, 2018 Accepting new patients
Allina Health System Past Accepting new patients

Locations

440 Elm St E
Annandale, MN 55302
Phone (320) 682-5225

10705 Town Square Dr NE
Ste 100
Minneapolis, MN 55449
Phone (763) 236-5400

2215 Park Ave
Minneapolis, MN 55404
Phone (612) 775-8800

2925 Chicago Ave
Minneapolis, MN 55407
Phone (612) 262-4813

2925 Chicago Ave
#10957
Minneapolis, MN 55407
Phone (612) 262-8640

Interoperability endpoints

  • Direct secure messaging: khall379090@excellian.direct.allina.com

Organizations & group practices 6

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 31

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 31

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1531872000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1604966400000",
    "number": "1841776242",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "10705 TOWN SQUARE DR NE STE 100",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "554498185",
            "telephone_number": "163-236-5400"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "10705 TOWN SQUARE DR NE #100",
            "city": "BLAINE",
            "state": "MN",
            "postal_code": "55449",
            "telephone_number": "763-236-5400"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BROBACK",
        "first_name": "KRISTIN",
        "credential": "NP, C",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2018-07-18",
        "last_updated": "2020-11-10",
        "certification_date": "2020-11-10",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363LF0000X",
            "taxonomy_group": "",
            "desc": "Nurse Practitioner, Family",
            "state": "MN",
            "license": "5976",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [
        {
            "endpointType": "DIRECT",
            "endpointTypeDescription": "Direct Messaging Address",
            "endpoint": "khall379090@excellian.direct.allina.com",
            "affiliation": "N",
            "use": "DIRECT",
            "useDescription": "Direct",
            "contentType": "OTHER",
            "contentTypeDescription": "Other",
            "contentOtherDescription": "CDA/PDF/TXT",
            "address_1": "10705 Town Square Dr NE #100",
            "city": "Blaine",
            "state": "MN",
            "country_code": "US",
            "postal_code": "55449",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "other_names": []
}

Other providers in Blaine, MN

Sources for this page

Verify at the official NPI Registry.