Healthcare Provider Details

I. General information

NPI: 1124388863
Provider Name (Legal Business Name): JENNIFER SORMAN GEDNALSKE PHARM. D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2012
Last Update Date: 02/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 OSBORNE RD NE MAIL CODE 52570
FRIDLEY MN
55432-2718
US

IV. Provider business mailing address

6174 LINDA LN
LINO LAKES MN
55014-6408
US

V. Phone/Fax

Practice location:
  • Phone: 763-236-4123
  • Fax:
Mailing address:
  • Phone: 651-340-2114
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number117455
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: