Healthcare Provider Details

I. General information

NPI: 1538829080
Provider Name (Legal Business Name): JENNIE NGUYEN TOLAND APRN, IBCLC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2021
Last Update Date: 01/26/2024
Certification Date: 01/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 W ROSS BLVD
DODGE CITY KS
67801-2131
US

IV. Provider business mailing address

120 W ROSS BLVD
DODGE CITY KS
67801-2131
US

V. Phone/Fax

Practice location:
  • Phone: 620-225-1605
  • Fax: 620-227-2505
Mailing address:
  • Phone: 620-225-1650
  • Fax: 620-227-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License Number135874
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number135874
License Number StateKS
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number53-82832
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: