Provider Demographics
NPI:1548240658
Name:ENGEBRETSON, LANICE ELIZABETH (RN CNP)
Entity Type:Individual
Prefix:
First Name:LANICE
Middle Name:ELIZABETH
Last Name:ENGEBRETSON
Suffix:
Gender:F
Credentials:RN CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 N. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:KIESTER
Mailing Address - State:MN
Mailing Address - Zip Code:56051
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-373-2384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-17
Last Update Date:2017-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 090896-6363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN093042300Medicaid
R04743Medicare UPIN
MN093042300Medicaid