Provider Demographics
NPI:1720482565
Name:BUNT, EMILY ELIZABETH (FNP)
Entity Type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:ELIZABETH
Last Name:BUNT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:EMILY
Other - Middle Name:ELIZABETH
Other - Last Name:BECKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:12152 85TH AVE N
Mailing Address - Street 2:
Mailing Address - City:MAPLE GROVE
Mailing Address - State:MN
Mailing Address - Zip Code:55369-4641
Mailing Address - Country:US
Mailing Address - Phone:612-214-4618
Mailing Address - Fax:
Practice Address - Street 1:3300 OAKDALE AVE N
Practice Address - Street 2:
Practice Address - City:ROBBINSDALE
Practice Address - State:MN
Practice Address - Zip Code:55422-2926
Practice Address - Country:US
Practice Address - Phone:763-581-0962
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-21
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR164694-2363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1720482565Medicaid