Healthcare Provider Details

I. General information

NPI: 1669950556
Provider Name (Legal Business Name): STEPHANIE JEAN BRECKENRIDGE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STEPHANIE JEAN BURGESS RN

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 06/13/2024
Certification Date: 06/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 W 98TH ST
BLOOMINGTON MN
55420-4773
US

IV. Provider business mailing address

16923 FESTAL AVE
FARMINGTON MN
55024-7825
US

V. Phone/Fax

Practice location:
  • Phone: 952-881-2651
  • Fax:
Mailing address:
  • Phone: 406-249-7056
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2063919
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201806936NP-PP
License Number StateOR
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number10772
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: