Healthcare Provider Details

I. General information

NPI: 1730722745
Provider Name (Legal Business Name): GRACE JEPCHIRCHIR FIDALGO RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 04/12/2022
Certification Date: 04/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6222 HEDGECROFT AVE S
COTTAGE GROVE MN
55016-6002
US

IV. Provider business mailing address

6222 HEDGECROFT AVE S
COTTAGE GROVE MN
55016-6002
US

V. Phone/Fax

Practice location:
  • Phone: 612-859-8250
  • Fax: 651-330-5351
Mailing address:
  • Phone: 612-859-8250
  • Fax: 651-330-5351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number2441890
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number1099897
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: