Healthcare Provider Details

I. General information

NPI: 1982950341
Provider Name (Legal Business Name): MAEGEN LYNN STORM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2012
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

IV. Provider business mailing address

200 1ST ST SW
ROCHESTER MN
55905-0001
US

V. Phone/Fax

Practice location:
  • Phone: 507-284-5233
  • Fax:
Mailing address:
  • Phone: 507-284-5233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberR180689-2
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2054
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: