1730411497 NPI number — MRS. KELLI MARIE JERDET ENGEN RN, BSN

Table of content: MRS. KELLI MARIE JERDET ENGEN RN, BSN (NPI 1730411497)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730411497 NPI number — MRS. KELLI MARIE JERDET ENGEN RN, BSN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
JERDET ENGEN
Provider First Name:
KELLI
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
RN, BSN
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:
1730411497
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N6520 GUY ROAD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BLACK RIVER FALLS
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
54615-1741
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
715-284-9851
Provider Business Mailing Address Fax Number:
715-284-5150

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N6520 GUY ROAD
Provider Second Line Business Practice Location Address:
HO-CHUNK HEALTH CARE CENTER
Provider Business Practice Location Address City Name:
BLACK RIVER FALLS
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
54615-1741
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
715-284-9851
Provider Business Practice Location Address Fax Number:
715-284-5150
Provider Enumeration Date:
02/05/2010

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: 163W00000X , with the licence number:  160751-030 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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