1649745159 NPI number — BRIDGET ANN JUHNKE PT, DPT

Table of content: BRIDGET ANN JUHNKE PT, DPT (NPI 1649745159)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1649745159 NPI number — BRIDGET ANN JUHNKE PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JUHNKE
Provider First Name:
BRIDGET
Provider Middle Name:
ANN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
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:
1649745159
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/04/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3101 49TH ST S APT 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FARGO
Provider Business Mailing Address State Name:
ND
Provider Business Mailing Address Postal Code:
58104-4528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
320-522-2262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4450 31ST AVE S STE 104
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FARGO
Provider Business Practice Location Address State Name:
ND
Provider Business Practice Location Address Postal Code:
58104-4557
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
701-451-9417
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
10/11/2018

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: 225100000X , with the licence number:  11326 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 225100000X , with the licence number: 2167 , 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: 2167 . This is a "PHYSICAL THERAPY LICENSE" identifier , issued by the state of ( ND ) . This identifiers is of the category "OTHER".
  • Identifier: 11326 . This is a "MN STATE PHYSICAL THERAPY LICENSE NUMBER" identifier , issued by the state of ( MN ) . This identifiers is of the category "OTHER".




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