1730191990 NPI number — ESTHER MARIE DOELE C-FNP

Table of content: ESTHER MARIE DOELE C-FNP (NPI 1730191990)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730191990 NPI number — ESTHER MARIE DOELE C-FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
DOELE
Provider First Name:
ESTHER
Provider Middle Name:
MARIE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
C-FNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WIELER
Provider Other First Name:
ESTHER
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1730191990
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/07/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
523 N 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRAINERD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56401-3054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-829-2861
Provider Business Mailing Address Fax Number:
507-223-7465

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14133 EDGEWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAXTER
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56425-8462
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-454-5802
Provider Business Practice Location Address Fax Number:
507-223-7465
Provider Enumeration Date:
08/13/2006

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: 363LF0000X , with the licence number:  R1073913 , 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)

  • Identifier: 807960900 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".




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