Provider Demographics
NPI:1619932100
Name:VANROEKEL KUISMI, LINDA RAE (RNC/FNP)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:RAE
Last Name:VANROEKEL KUISMI
Suffix:
Gender:F
Credentials:RNC/FNP
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:RAE
Other - Last Name:KUISMI
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RNC/FNP
Mailing Address - Street 1:56139 110TH ST
Mailing Address - Street 2:
Mailing Address - City:MENAHGA
Mailing Address - State:MN
Mailing Address - Zip Code:56464-2109
Mailing Address - Country:US
Mailing Address - Phone:218-844-5832
Mailing Address - Fax:218-844-5834
Practice Address - Street 1:1125 W RIVER RD
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501-2722
Practice Address - Country:US
Practice Address - Phone:218-844-5832
Practice Address - Fax:218-844-5834
Is Sole Proprietor?:No
Enumeration Date:2006-04-19
Last Update Date:2019-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNNP098824-5363LF0000X
MN2515363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR04776Medicare UPIN