Healthcare Provider Details

I. General information

NPI: 1578821419
Provider Name (Legal Business Name): JILL RENAE ZIMMERMANN RN, IBCLC, PHN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2012
Last Update Date: 04/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9433 PARKSIDE CT
CHAMPLIN MN
55316-2604
US

IV. Provider business mailing address

9433 PARKSIDE CT
CHAMPLIN MN
55316-2604
US

V. Phone/Fax

Practice location:
  • Phone: 763-486-8123
  • Fax:
Mailing address:
  • Phone: 763-486-8123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WL0100X
TaxonomyLactation Consultant (Registered Nurse)
License NumberR112787-2
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: