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Individual

MARION CONWELL

Active
Sole proprietor
Yes

Provider details

NPI number
Gender
F

Contact information

Practice address
12521 OTTO ST, ROGERS, MN 55374-9199
(763) 229-6014
Mailing address
12521 OTTO ST, ROGERS, MN 55374-9199
(763) 229-6014

Taxonomy

Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
X694280447419
MN

Other

Other identifiers
Code
Description
Identifier
Issuer
State
01
01014569
MINNESOTA HEALTH CARE PROGRAMS
MN
Enumeration date
06/02/2016
Last updated
06/02/2016
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