Healthcare Provider Details

I. General information

NPI: 1962486126
Provider Name (Legal Business Name): ANGELA MILLER BASTIAN APRN, CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/01/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

410 S 5TH ST
MANKATO MN
56001-4588
US

IV. Provider business mailing address

317 OAK KNOLL BLVD
MANKATO MN
56001-2616
US

V. Phone/Fax

Practice location:
  • Phone: 507-304-4319
  • Fax: 507-304-4387
Mailing address:
  • Phone: 507-387-3217
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberR 155512-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: