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General NPI Number Information
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NPI Number | 1174353825
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Entity Type | Individual
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Provider Name | MS. DENETTE MAMIE PHILLIPS DUNN
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Gender | Female
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Dates
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Enumeration Date | 08/07/2024
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Last Update Date | 08/07/2024
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Provider Practice Location Address
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Address Line | 10527 165TH ST W
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City | LAKEVILLE
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State | MN
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Zip | 55044-5725
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Country | US
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Telephone | 952-955-4110
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 20411
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City | BLOOMINGTON
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State | MN
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Zip | 55420-0411
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Country | US
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Telephone | 612-702-2222
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 2477500
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License Number State | MN
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | 2024012143
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License Number State | MN
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