Provider Demographics
NPI:1932655420
Name:RAKKE, TAMARA LOIS (AGPCNP)
Entity Type:Individual
Prefix:
First Name:TAMARA
Middle Name:LOIS
Last Name:RAKKE
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 MAIN ST N STE 300
Mailing Address - Street 2:
Mailing Address - City:STILLWATER
Mailing Address - State:MN
Mailing Address - Zip Code:55082-6788
Mailing Address - Country:US
Mailing Address - Phone:651-342-1039
Mailing Address - Fax:651-342-1428
Practice Address - Street 1:270 MAIN ST N STE 300
Practice Address - Street 2:
Practice Address - City:STILLWATER
Practice Address - State:MN
Practice Address - Zip Code:55082
Practice Address - Country:US
Practice Address - Phone:651-342-1039
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-25
Last Update Date:2024-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4677363LA2200X
WAAP60720346363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8961504, G8961505Medicare PIN
WAG8961504, G8961505Medicare PIN
WA1932655420Medicaid