1477128072 NPI number — SUE EVANS RN

Table of content: SUE EVANS RN (NPI 1477128072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477128072 NPI number — SUE EVANS RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
EVANS
Provider First Name:
SUE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN
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:
1477128072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
317 IRENE AVE.
Provider Second Line Business Mailing Address:
P.O. BOX 1
Provider Business Mailing Address City Name:
IRONTON
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
56455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-546-6242
Provider Business Mailing Address Fax Number:
218-772-0326

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
317 IRENE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
IRONTON
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
56455
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-546-6242
Provider Business Practice Location Address Fax Number:
218-772-0326
Provider Enumeration Date:
05/25/2021

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: 163WH0200X , with the licence number:  1965021 , 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: 1669628921 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1124458005 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".