Provider Demographics
NPI:1134105703
Name:LOFBERG, KATHERINE LILLIE (FNP-C)
Entity Type:Individual
Prefix:
First Name:KATHERINE
Middle Name:LILLIE
Last Name:LOFBERG
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W GRANT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55041-1143
Mailing Address - Country:US
Mailing Address - Phone:651-345-3321
Mailing Address - Fax:651-345-1151
Practice Address - Street 1:500 W GRANT ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:MN
Practice Address - Zip Code:55041-1143
Practice Address - Country:US
Practice Address - Phone:651-345-3321
Practice Address - Fax:651-345-1151
Is Sole Proprietor?:No
Enumeration Date:2005-12-15
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1070084363L00000X
MN56363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN662647500Medicaid
500001247Medicare ID - Type Unspecified
MN662647500Medicaid