Provider Demographics
NPI:1265834535
Name:FUGLEBERG, ERIN LOUISE
Entity Type:Individual
Prefix:
First Name:ERIN
Middle Name:LOUISE
Last Name:FUGLEBERG
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 1:317 GROVELAND AVE UNIT 312
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3661
Mailing Address - Country:US
Mailing Address - Phone:612-615-5054
Mailing Address - Fax:
Practice Address - Street 1:317 GROVELAND AVE UNIT 312
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3661
Practice Address - Country:US
Practice Address - Phone:612-615-5054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI189376-30163W00000X
MNR-184126-8163W00000X
MN104971367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse