Provider Demographics
NPI:1003229204
Name:BACH, NAOMI NOELLE
Entity Type:Individual
Prefix:
First Name:NAOMI
Middle Name:NOELLE
Last Name:BACH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1018 6TH AVE
Mailing Address - Street 2:PO BOX 997
Mailing Address - City:WORTHINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:56187-2202
Mailing Address - Country:US
Mailing Address - Phone:507-372-3271
Mailing Address - Fax:
Practice Address - Street 1:1018 6TH AVE
Practice Address - Street 2:
Practice Address - City:WORTHINGTON
Practice Address - State:MN
Practice Address - Zip Code:56187-2202
Practice Address - Country:US
Practice Address - Phone:507-372-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-04
Last Update Date:2014-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA108831163WE0900X
IAA108831363LF0000X
MNR2204752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WE0900XNursing Service ProvidersRegistered NurseEnterostomal Therapy
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily