Provider Demographics
NPI:1275844011
Name:BERTRAM, BOBBIE JO (RN, CNP)
Entity Type:Individual
Prefix:MRS
First Name:BOBBIE
Middle Name:JO
Last Name:BERTRAM
Suffix:
Gender:F
Credentials:RN, CNP
Other - Prefix:MS
Other - First Name:BOBBIE
Other - Middle Name:JO
Other - Last Name:BANKEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1406 6TH AVE N
Mailing Address - Street 2:ST. CLOUD HOSPITAL
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-1900
Mailing Address - Country:US
Mailing Address - Phone:320-255-5656
Mailing Address - Fax:320-656-7044
Practice Address - Street 1:1406 6TH AVE N
Practice Address - Street 2:ST. CLOUD HOSPITAL
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-1900
Practice Address - Country:US
Practice Address - Phone:320-255-5656
Practice Address - Fax:320-656-7044
Is Sole Proprietor?:No
Enumeration Date:2010-06-26
Last Update Date:2014-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-156834-7363LF0000X
MNR156834363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNPENDMedicaid
PENDMedicare PIN