Provider Demographics
NPI:1518399989
Name:ABRAHAM, ANN MARIE (PHN)
Entity Type:Individual
Prefix:
First Name:ANN
Middle Name:MARIE
Last Name:ABRAHAM
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:607 W MAIN ST
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-3169
Mailing Address - Country:US
Mailing Address - Phone:507-532-1274
Mailing Address - Fax:
Practice Address - Street 1:607 W MAIN ST
Practice Address - Street 2:SUITE 200
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-3169
Practice Address - Country:US
Practice Address - Phone:507-532-1274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2013-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 116284-0163W00000X
MN20781163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA745498000Medicaid