Provider Demographics
NPI:1235251893
Name:IMGRUND, BECKY JO (NP)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:JO
Last Name:IMGRUND
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 1:13819 102ND PL N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-7501
Mailing Address - Country:US
Mailing Address - Phone:303-548-6564
Mailing Address - Fax:
Practice Address - Street 1:111 HUNDERTMARK RD
Practice Address - Street 2:
Practice Address - City:CHASKA
Practice Address - State:MN
Practice Address - Zip Code:55318-4551
Practice Address - Country:US
Practice Address - Phone:952-442-2191
Practice Address - Fax:952-442-8055
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO106752363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
COP00739790OtherRR MEDICARE
CO54503744Medicaid
COP00739790OtherRR MEDICARE