Provider Demographics
NPI:1164717005
Name:HINNENKAMP, LUANN T
Entity Type:Individual
Prefix:
First Name:LUANN
Middle Name:T
Last Name:HINNENKAMP
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3018 36TH AVE S
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58104-8844
Mailing Address - Country:US
Mailing Address - Phone:701-298-8285
Mailing Address - Fax:
Practice Address - Street 1:3018 36TH AVE S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58104-8844
Practice Address - Country:US
Practice Address - Phone:701-298-8285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-17
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDHIN-58-6702172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver