Provider Demographics
NPI:1457753295
Name:ZIMMERMAN-DESCHEPPER, TRACY (APRN)
Entity Type:Individual
Prefix:
First Name:TRACY
Middle Name:
Last Name:ZIMMERMAN-DESCHEPPER
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 NW 4TH STREET
Mailing Address - Street 2:SUITE A
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55744-2714
Mailing Address - Country:US
Mailing Address - Phone:218-999-7750
Mailing Address - Fax:218-999-9461
Practice Address - Street 1:28 NW 4TH STREET
Practice Address - Street 2:SUITE A
Practice Address - City:GRAND RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55744-2714
Practice Address - Country:US
Practice Address - Phone:218-326-1274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2023-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2014011459363LP0808X
MNCNP3914363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNCO8154OtherMEDICARE PTAN
MN72560NOOtherBCBS
MN894755400Medicaid