Healthcare Provider Details

I. General information

NPI: 1881791523
Provider Name (Legal Business Name): AGNES LEONELLA FAUNDEEN FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

3110 SANTA FE TRL
SAINT CLOUD MN
56301-9140
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6480
  • Fax:
Mailing address:
  • Phone: 320-253-8027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR 73027-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: