Healthcare Provider Details

I. General information

NPI: 1306216593
Provider Name (Legal Business Name): RACHEL SUZANNE GUPTA R.N., B.S.N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/30/2015
Last Update Date: 09/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17087 TRILLIUM LN
BIG LAKE MN
55309-5202
US

IV. Provider business mailing address

17087 TRILLIUM LN
BIG LAKE MN
55309-5202
US

V. Phone/Fax

Practice location:
  • Phone: 763-682-3005
  • Fax:
Mailing address:
  • Phone: 763-682-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 230127-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: