Provider Demographics
NPI:1376763458
Name:LOXTERCAMP, MARY JEAN (LPN)
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:JEAN
Last Name:LOXTERCAMP
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:JEAN
Other - Last Name:GATES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:618 N 8TH ST
Mailing Address - Street 2:
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2608
Mailing Address - Country:US
Mailing Address - Phone:218-825-8658
Mailing Address - Fax:
Practice Address - Street 1:106 NORTH 4TH AVENUE
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:218-998-3187
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL0637208164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse