Provider Demographics
NPI:1962872994
Name:VANDENDRIESSCHE, BOBBI JO
Entity type:Individual
Prefix:
First Name:BOBBI JO
Middle Name:
Last Name:VANDENDRIESSCHE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 CARLSON ST
Mailing Address - Street 2:
Mailing Address - City:MARSHALL
Mailing Address - State:MN
Mailing Address - Zip Code:56258-2626
Mailing Address - Country:US
Mailing Address - Phone:507-532-1101
Mailing Address - Fax:507-532-1137
Practice Address - Street 1:1521 CARLSON ST
Practice Address - Street 2:
Practice Address - City:MARSHALL
Practice Address - State:MN
Practice Address - Zip Code:56258-2626
Practice Address - Country:US
Practice Address - Phone:507-532-1101
Practice Address - Fax:507-532-1137
Is Sole Proprietor?:No
Enumeration Date:2015-10-02
Last Update Date:2015-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCNP4205363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner