Healthcare Provider Details

I. General information

NPI: 1467558197
Provider Name (Legal Business Name): AIMEE LYN TEBRAKE CNS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 06/23/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 2ND ST SW
WILLMAR MN
56201-3365
US

IV. Provider business mailing address

502 2ND ST SW
WILLMAR MN
56201-3365
US

V. Phone/Fax

Practice location:
  • Phone: 320-235-7232
  • Fax: 320-231-8609
Mailing address:
  • Phone: 320-235-7232
  • Fax: 320-231-8609

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364S00000X
TaxonomyClinical Nurse Specialist
License NumberR 1189056
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: