Healthcare Provider Details

I. General information

NPI: 1932562188
Provider Name (Legal Business Name): JENNIE GAPPA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/04/2016
Last Update Date: 12/02/2020
Certification Date: 12/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

251 5TH ST E
TRACY MN
56175-1536
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 507-629-8400
  • Fax:
Mailing address:
  • Phone: 605-328-6585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1915
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: