Provider Demographics
NPI:1780662544
Name:NITZ, DELAYNA A (NP)
Entity Type:Individual
Prefix:
First Name:DELAYNA
Middle Name:A
Last Name:NITZ
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 7TH ST NW
Mailing Address - Street 2:
Mailing Address - City:CASS LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56633-3360
Mailing Address - Country:US
Mailing Address - Phone:218-335-3200
Mailing Address - Fax:
Practice Address - Street 1:425 7TH ST NW
Practice Address - Street 2:
Practice Address - City:CASS LAKE
Practice Address - State:MN
Practice Address - Zip Code:56633-3360
Practice Address - Country:US
Practice Address - Phone:218-335-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2023-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-170159-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN421495100Medicaid
MN500003206Medicare ID - Type Unspecified
Q56375Medicare UPIN
MN500004121Medicare PIN