Provider Demographics
NPI:1912219130
Name:BLONIGEN, AMANDA SUE
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:SUE
Last Name:BLONIGEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3332 OAK STREET
Mailing Address - Street 2:APT. G
Mailing Address - City:BRAINERD
Mailing Address - State:MN
Mailing Address - Zip Code:56401
Mailing Address - Country:US
Mailing Address - Phone:320-491-4984
Mailing Address - Fax:
Practice Address - Street 1:106 4TH AVE N.
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-1034
Practice Address - Country:US
Practice Address - Phone:218-998-3778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-02
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL69547-3164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse