Healthcare Provider Details

I. General information

NPI: 1013417344
Provider Name (Legal Business Name): JENNY LYNN ROLLER RNFA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2018
Last Update Date: 02/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 JEFFERSON ST N
WADENA MN
56482-1264
US

IV. Provider business mailing address

60611 260TH ST
HEWITT MN
56453-4026
US

V. Phone/Fax

Practice location:
  • Phone: 218-631-3510
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number2139296
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: