Provider Demographics
NPI:1972518462
Name:JUTSUM, VIVIEN H (APRN)
Entity Type:Individual
Prefix:
First Name:VIVIEN
Middle Name:H
Last Name:JUTSUM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:VIVIEN
Other - Middle Name:H
Other - Last Name:HORROCKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:920 BELL AVE
Mailing Address - Street 2:
Mailing Address - City:WESTBROOK
Mailing Address - State:MN
Mailing Address - Zip Code:56183-9669
Mailing Address - Country:US
Mailing Address - Phone:507-274-6121
Mailing Address - Fax:507-274-5630
Practice Address - Street 1:920 BELL AVE
Practice Address - Street 2:
Practice Address - City:WESTBROOK
Practice Address - State:MN
Practice Address - Zip Code:56183-9669
Practice Address - Country:US
Practice Address - Phone:507-274-6121
Practice Address - Fax:507-274-5630
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2008-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1598508363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN500002388Medicare PIN
MNP00064791Medicare PIN
S88108Medicare UPIN