Healthcare Provider Details

I. General information

NPI: 1437983764
Provider Name (Legal Business Name): AMY EVANS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AMY BLOMQUIST

II. Dates (important events)

Enumeration Date: 08/28/2024
Last Update Date: 10/11/2024
Certification Date: 10/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4688 OTTER CT NE
SAINT MICHAEL MN
55376-2222
US

IV. Provider business mailing address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

V. Phone/Fax

Practice location:
  • Phone: 763-447-5411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number1907319
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number1907319
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: