Provider Demographics
NPI:1679673503
Name:FOOTE MILBRANDT, PHYLLIS A (RN MA LP)
Entity Type:Individual
Prefix:
First Name:PHYLLIS
Middle Name:A
Last Name:FOOTE MILBRANDT
Suffix:
Gender:F
Credentials:RN MA LP
Other - Prefix:
Other - First Name:PHYLLIS
Other - Middle Name:A
Other - Last Name:FOOTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:401 DIVISION STREET
Mailing Address - Street 2:SUITE C
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057
Mailing Address - Country:US
Mailing Address - Phone:507-645-6249
Mailing Address - Fax:507-645-0269
Practice Address - Street 1:401 DIVISION STREET
Practice Address - Street 2:SUITE C
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057
Practice Address - Country:US
Practice Address - Phone:507-645-6249
Practice Address - Fax:507-645-0269
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3374103T00000X
MNR0691053163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN48B03FOOtherBLUE CROSS BLUE SHIELD
MN529167400Medicaid
MN620000274Medicare PIN