Healthcare Provider Details

I. General information

NPI: 1568234706
Provider Name (Legal Business Name): TRICIA R HANSEN RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRICIA R BOLEJACK

II. Dates (important events)

Enumeration Date: 10/23/2023
Last Update Date: 10/23/2023
Certification Date: 10/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3251 W 9TH ST
WATERLOO IA
50702-5399
US

IV. Provider business mailing address

3251 W 9TH ST
WATERLOO IA
50702-5399
US

V. Phone/Fax

Practice location:
  • Phone: 319-234-2893
  • Fax: 319-234-0354
Mailing address:
  • Phone: 319-234-2893
  • Fax: 319-234-0354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number154329
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: