1134378433 NPI number — MRS. MANDY RAE BLUME MS RN CGNP

Table of content: MRS. MANDY RAE BLUME MS RN CGNP (NPI 1134378433)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134378433 NPI number — MRS. MANDY RAE BLUME MS RN CGNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BLUME
Provider First Name:
MANDY
Provider Middle Name:
RAE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS RN CGNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BUTTERFIELD
Provider Other First Name:
MANDY
Provider Other Middle Name:
RAE
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS RN CGNP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1134378433
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/02/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4810 197TH ST E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARIBAULT
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55021-8078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
507-333-2748
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4810 197TH ST E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARIBAULT
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55021-8078
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
507-333-2748
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/11/2008

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: 363LG0600X , with the licence number:  R156724-1 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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