Healthcare Provider Details

I. General information

NPI: 1770889669
Provider Name (Legal Business Name): JESSICA JEAN CUNNINGHAM RN, LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2011
Last Update Date: 02/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30286 FOX RUN RD
STACY MN
55079-9653
US

IV. Provider business mailing address

30286 FOX RUN RD
STACY MN
55079-9653
US

V. Phone/Fax

Practice location:
  • Phone: 651-269-3362
  • Fax:
Mailing address:
  • Phone: 651-269-3362
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR 199450-0
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL 067912-7
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: