Healthcare Provider Details

I. General information

NPI: 1275902025
Provider Name (Legal Business Name): ILSA ANNE SIEG FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/23/2015
Last Update Date: 08/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

67 10TH AVE S
WAITE PARK MN
56387-1040
US

IV. Provider business mailing address

67 10TH AVE S
WAITE PARK MN
56387-1040
US

V. Phone/Fax

Practice location:
  • Phone: 320-774-1083
  • Fax:
Mailing address:
  • Phone: 320-774-1083
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP4113
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: