Provider Demographics
NPI:1134378433
Name:BLUME, MANDY RAE (MS RN CGNP)
Entity type:Individual
Prefix:MRS
First Name:MANDY
Middle Name:RAE
Last Name:BLUME
Suffix:
Gender:F
Credentials:MS RN CGNP
Other - Prefix:MISS
Other - First Name:MANDY
Other - Middle Name:RAE
Other - Last Name:BUTTERFIELD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RN CGNP
Mailing Address - Street 1:4810 197TH ST E
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-8078
Mailing Address - Country:US
Mailing Address - Phone:507-333-2748
Mailing Address - Fax:
Practice Address - Street 1:4810 197TH ST E
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-8078
Practice Address - Country:US
Practice Address - Phone:507-333-2748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-11
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR156724-1363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology