Healthcare Provider Details

I. General information

NPI: 1174963706
Provider Name (Legal Business Name): GILLIAN GLASS SCHOENBAUER NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GILLIAN MARY GLASS

II. Dates (important events)

Enumeration Date: 06/27/2013
Last Update Date: 03/11/2021
Certification Date: 03/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 XERXES AVE S
BLOOMINGTON MN
55431-1253
US

IV. Provider business mailing address

712 BACHELOR AVE
MENDOTA HEIGHTS MN
55118-3701
US

V. Phone/Fax

Practice location:
  • Phone: 952-888-2024
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 177280-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: