Healthcare Provider Details

I. General information

NPI: 1417030081
Provider Name (Legal Business Name): TIPARPA CHITASOMBAT CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TIPARPA RUNGSEEVONG

II. Dates (important events)

Enumeration Date: 10/24/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

451 NORTH DUNLAP STREET MAIL STOP 32700A
ST PAUL MN
55104-4621
US

IV. Provider business mailing address

8100 34TH AVE S 21110Q
BLOOMINGTON MN
55425-1672
US

V. Phone/Fax

Practice location:
  • Phone: 651-999-4700
  • Fax: 651-999-4781
Mailing address:
  • Phone: 952-883-5463
  • Fax: 952-883-5395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR1307223
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: