Provider Demographics
NPI:1982718896
Name:VAN DER VALK, IRMA JOHANNA (NP)
Entity Type:Individual
Prefix:
First Name:IRMA
Middle Name:JOHANNA
Last Name:VAN DER VALK
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 LANE PL
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-2807
Mailing Address - Country:US
Mailing Address - Phone:651-264-1345
Mailing Address - Fax:
Practice Address - Street 1:1925 WOODWINDS DR
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-2270
Practice Address - Country:US
Practice Address - Phone:651-232-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR148448-9363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN550617400Medicaid
MN550617400Medicaid