Provider Demographics
NPI:1790701241
Name:GRUNEFELDER, JACQUELINE MARIE (FNPC)
Entity Type:Individual
Prefix:
First Name:JACQUELINE
Middle Name:MARIE
Last Name:GRUNEFELDER
Suffix:
Gender:F
Credentials:FNPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1955 HWY 34
Mailing Address - Street 2:
Mailing Address - City:KINTYRE
Mailing Address - State:ND
Mailing Address - Zip Code:58549
Mailing Address - Country:US
Mailing Address - Phone:701-332-6314
Mailing Address - Fax:701-254-5459
Practice Address - Street 1:511 ELM AVE
Practice Address - Street 2:LINTON MEDICAL CENTER
Practice Address - City:LINTON
Practice Address - State:ND
Practice Address - Zip Code:58552
Practice Address - Country:US
Practice Address - Phone:701-254-4531
Practice Address - Fax:701-254-5459
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2020-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR26709363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND26435OtherBCBS
ND19814Medicaid
ND26435OtherBCBS
ND19814Medicaid