Provider Demographics
NPI: | 1164400800 |
---|---|
Name: | ERICKSEN, JOANNE R (CNS) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOANNE |
Middle Name: | R |
Last Name: | ERICKSEN |
Suffix: | |
Gender: | F |
Credentials: | CNS |
Other - Prefix: | |
Other - First Name: | |
Other - Middle Name: | |
Other - Last Name: | |
Other - Suffix: | |
Other - Last Name Type: | |
Other - Credentials: | |
Mailing Address - Street 1: | 200 1ST ST SW |
Mailing Address - Street 2: | |
Mailing Address - City: | ROCHESTER |
Mailing Address - State: | MN |
Mailing Address - Zip Code: | 55905-0001 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 507-284-2511 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 200 1ST ST SW |
Practice Address - Street 2: | |
Practice Address - City: | ROCHESTER |
Practice Address - State: | MN |
Practice Address - Zip Code: | 55905-0001 |
Practice Address - Country: | US |
Practice Address - Phone: | 507-284-2511 |
Practice Address - Fax: | |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-01-04 |
Last Update Date: | 2009-06-18 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MN | R119339-8 | 364S00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 364S00000X | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
MN | 731827800 | Medicaid | |
MN | ENROLLED | Medicaid | |
MN | 890000622 | Medicare ID - Type Unspecified | RAILROAD |
MN | 890000461 | Medicare PIN | |
MN | 731827800 | Medicaid | |
MN | 890000050 | Medicare ID - Type Unspecified |