=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205122017
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | PAMELA JEAN BLENDERMANN PT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2011
-----------------------------------------------------
Last Update Date | 10/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23490 HIGHWAY 7
-----------------------------------------------------
City | SHOREWOOD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55331-3141
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-888-9882
-----------------------------------------------------
Fax | 612-888-9886
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1939 MINNEHAHA AVE W STE 300
-----------------------------------------------------
City | SAINT PAUL
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55104-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 651-748-4338
-----------------------------------------------------
Fax | 651-748-2892
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 8729
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------