Provider Demographics
NPI:1134482599
Name:VINGELEN, AMANDA JEAN (OTRL)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:JEAN
Last Name:VINGELEN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:JEAN
Other - Last Name:RALSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:2401 DEMERS AVE
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201
Mailing Address - Country:US
Mailing Address - Phone:701-780-1891
Mailing Address - Fax:701-780-4477
Practice Address - Street 1:1300 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201
Practice Address - Country:US
Practice Address - Phone:701-780-5000
Practice Address - Fax:701-780-4477
Is Sole Proprietor?:No
Enumeration Date:2012-06-20
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN104259225X00000X, 225XP0019X
ND1278225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0019XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPhysical Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN670000923Medicare PIN