Provider Demographics
NPI:1689648230
Name:FELLMAN, GAIL A (GNP)
Entity Type:Individual
Prefix:
First Name:GAIL
Middle Name:A
Last Name:FELLMAN
Suffix:
Gender:F
Credentials:GNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8170 33RD AVE S
Mailing Address - Street 2:MC21110Q
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55425-4516
Mailing Address - Country:US
Mailing Address - Phone:952-883-6805
Mailing Address - Fax:952-883-6117
Practice Address - Street 1:8170 33RD AVE S
Practice Address - Street 2:MC21110Q
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55425-4516
Practice Address - Country:US
Practice Address - Phone:952-883-6805
Practice Address - Fax:952-883-6117
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1128703363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN482400800Medicaid
500001642Medicare ID - Type Unspecified
S94715Medicare UPIN