Provider Demographics
NPI:1467025304
Name:BENGTSON, TINA (NP-C)
Entity Type:Individual
Prefix:
First Name:TINA
Middle Name:
Last Name:BENGTSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:TINA
Other - Middle Name:
Other - Last Name:MICKOLICHEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8936 LYNDALE AVE S
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-2742
Mailing Address - Country:US
Mailing Address - Phone:952-881-0163
Mailing Address - Fax:
Practice Address - Street 1:440 ELM ST E
Practice Address - Street 2:
Practice Address - City:ANNANDALE
Practice Address - State:MN
Practice Address - Zip Code:55302-1109
Practice Address - Country:US
Practice Address - Phone:320-274-3744
Practice Address - Fax:320-274-8194
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN8311363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily