Provider Demographics
NPI:1750553699
Name:MORTENSON, MONICA JOY (CRNA)
Entity type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:JOY
Last Name:MORTENSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11715 JEWEL CT NE
Mailing Address - Street 2:
Mailing Address - City:BLAINE
Mailing Address - State:MN
Mailing Address - Zip Code:55449-5876
Mailing Address - Country:US
Mailing Address - Phone:763-767-1843
Mailing Address - Fax:
Practice Address - Street 1:11715 JEWEL CT NE
Practice Address - Street 2:
Practice Address - City:BLAINE
Practice Address - State:MN
Practice Address - Zip Code:55449-5876
Practice Address - Country:US
Practice Address - Phone:763-767-1843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN078542367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered