1356431894 NPI number — MS. DONNA M WACKER FNP-C

Table of content: MS. DONNA M WACKER FNP-C (NPI 1356431894)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356431894 NPI number — MS. DONNA M WACKER FNP-C

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WACKER
Provider First Name:
DONNA
Provider Middle Name:
M
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
FNP-C
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:
1356431894
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1951 MAIN ST W
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TURTLE LAKE
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58575-9661
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
701-628-2505
Provider Business Mailing Address Fax Number:
701-628-3274

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
615 6 ST SE
Provider Second Line Business Practice Location Address:
MOUNTRAIL COUNTY MEDICAL CENTER
Provider Business Practice Location Address City Name:
STANLEY
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58784
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-628-2505
Provider Business Practice Location Address Fax Number:
701-628-3274
Provider Enumeration Date:
10/13/2006

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:  R26295 , registered in the state of ND ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 19843 , issued by the state of ( ND ) . This identifiers is of the category "MEDICAID".




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