Provider Demographics
NPI:1164603460
Name:BERTILRUD, DESIREE M (NP)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:M
Last Name:BERTILRUD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 HIGHWAY 59 S
Mailing Address - Street 2:
Mailing Address - City:THIEF RIVER FALLS
Mailing Address - State:MN
Mailing Address - Zip Code:56701-4331
Mailing Address - Country:US
Mailing Address - Phone:218-681-4747
Mailing Address - Fax:218-683-2595
Practice Address - Street 1:1720 HIGHWAY 59 S
Practice Address - Street 2:
Practice Address - City:THIEF RIVER FALLS
Practice Address - State:MN
Practice Address - Zip Code:56701-4331
Practice Address - Country:US
Practice Address - Phone:218-681-4747
Practice Address - Fax:218-683-2595
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2008-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR156913-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN0836113000Medicaid