1396207353 NPI number — MRS. JOYCELYN AMPON WILSON CRNA

Table of content: MRS. JOYCELYN AMPON WILSON CRNA (NPI 1396207353)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396207353 NPI number — MRS. JOYCELYN AMPON WILSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JOYCELYN
Provider Middle Name:
AMPON
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
AMPON
Provider Other First Name:
JOYCELYN
Provider Other Middle Name:
COBRADOR
Provider Other Name Prefix Text:
MISS
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1396207353
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/01/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4401 PARK GLEN RD APT 301
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:
55416-4767
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-352-7728
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
333 SMITH AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55102-2344
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
651-241-8000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/01/2019

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: 367500000X , with the licence number:  2208091 , 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: 122707 . This is a "NBCRNA CREDENTIAL ID" identifier . This identifiers is of the category "OTHER".
  • Identifier: 2208091 . This is a "MINNESOTA RN LICENSE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".