Provider Demographics
NPI:1114426657
Name:STRACK, RAINYA JADE
Entity Type:Individual
Prefix:
First Name:RAINYA
Middle Name:JADE
Last Name:STRACK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RAINYA
Other - Middle Name:JADE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:509 5TH ST SW
Mailing Address - Street 2:
Mailing Address - City:LITTLE FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56345-1716
Mailing Address - Country:US
Mailing Address - Phone:320-423-1652
Mailing Address - Fax:
Practice Address - Street 1:3700 W DIVISION ST STE 105
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56301-4031
Practice Address - Country:US
Practice Address - Phone:320-423-1652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-11
Last Update Date:2018-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN059237-2164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse