Provider Demographics
NPI:1811266000
Name:GORSEGNER, CAMILLE KAY (LPN)
Entity type:Individual
Prefix:
First Name:CAMILLE
Middle Name:KAY
Last Name:GORSEGNER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 3RD AVE SE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063
Mailing Address - Country:US
Mailing Address - Phone:320-629-6674
Mailing Address - Fax:320-629-6630
Practice Address - Street 1:500 3RD AVE SE
Practice Address - Street 2:SUITE 2
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063
Practice Address - Country:US
Practice Address - Phone:320-629-6674
Practice Address - Fax:320-629-6630
Is Sole Proprietor?:No
Enumeration Date:2011-12-19
Last Update Date:2011-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNL61496-2164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse