1043388192 NPI number — MRS. DONNA JEAN AMIDON CNP

Table of content: MRS. DONNA JEAN AMIDON CNP (NPI 1043388192)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043388192 NPI number — MRS. DONNA JEAN AMIDON CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
AMIDON
Provider First Name:
DONNA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043388192
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
308 PARKWAY COURT
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MINNEAPOLIS
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
612-824-5401
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
250 SO 4TH ST ROOM 510
Provider Second Line Business Practice Location Address:
MPLS DEPT OF HEALTH & FAMILY SUPPORT SCHOOL BASED CLIN
Provider Business Practice Location Address City Name:
MINNEAPOLIS
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-673-5305
Provider Business Practice Location Address Fax Number:
612-673-3866
Provider Enumeration Date:
11/30/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  R0634023 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .
  • Taxonomy code: 363LP0200X , with the licence number: 82001 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "X" .

Other Provider's Identifiers (legacy, non-NPI)