Healthcare Provider Details

I. General information

NPI: 1902102916
Provider Name (Legal Business Name): JENNA SUE FICKBOHM L.P.N
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2011
Last Update Date: 02/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13483 COUNTY ROAD F
GRANTSBURG WI
54840-7363
US

IV. Provider business mailing address

13483 COUNTY ROAD F
GRANTSBURG WI
54840-7363
US

V. Phone/Fax

Practice location:
  • Phone: 651-353-5535
  • Fax:
Mailing address:
  • Phone: 651-353-5535
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberL068049-1
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: