Healthcare Provider Details

I. General information

NPI: 1255041703
Provider Name (Legal Business Name): LESA JO THIELKE APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2022
Last Update Date: 11/24/2022
Certification Date: 08/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 S BEHL ST
APPLETON MN
56208-1616
US

IV. Provider business mailing address

30 S BEHL ST
APPLETON MN
56208-1616
US

V. Phone/Fax

Practice location:
  • Phone: 320-289-1580
  • Fax:
Mailing address:
  • Phone: 320-289-1580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9759
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: