Provider Demographics
NPI:1518906437
Name:GAGNER-TJELLESEN, DESIREE JOANNE (RNCS,APRN,BC)
Entity Type:Individual
Prefix:
First Name:DESIREE
Middle Name:JOANNE
Last Name:GAGNER-TJELLESEN
Suffix:
Gender:F
Credentials:RNCS,APRN,BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:151 S 4TH ST
Mailing Address - Street 2:SUITE 401
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-4715
Mailing Address - Country:US
Mailing Address - Phone:701-795-3000
Mailing Address - Fax:701-795-3050
Practice Address - Street 1:151 S 4TH ST
Practice Address - Street 2:SUITE 401
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4715
Practice Address - Country:US
Practice Address - Phone:701-795-3000
Practice Address - Fax:701-795-3050
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-06
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR24745364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN638R1GAOtherBCBS MN PROVIDER NUMBER
ND020043OtherBCBS ND PROVIDER NUMBER
ND054519Medicaid
ND054519Medicaid
MN638R1GAOtherBCBS MN PROVIDER NUMBER
P54542Medicare UPIN