Provider Demographics
NPI:1649318726
Name:HIEMENZ, CHARLES LEE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:LEE
Last Name:HIEMENZ
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 RIVERSIDE DR NE
Mailing Address - Street 2:
Mailing Address - City:ST. CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56304-0435
Mailing Address - Country:US
Mailing Address - Phone:320-259-7637
Mailing Address - Fax:
Practice Address - Street 1:4801 8TH ST N
Practice Address - Street 2:
Practice Address - City:ST. CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2099
Practice Address - Country:US
Practice Address - Phone:320-252-1670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR086748-9363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology