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General NPI Number Information
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NPI Number | 1316759566
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Entity Type | Organization
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Legal Business Name | SUMMIT ADVANCE MOBILE WOUND CARE LLC
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Dates
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Enumeration Date | 01/24/2025
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Last Update Date | 01/24/2025
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Provider Practice Location Address
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Address Line | 6773 DEERWOOD LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55369-5530
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Country | US
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Telephone | 612-598-8555
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Fax |
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Provider Business Mailing Address
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Address Line | 6773 DEERWOOD LN N
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City | MAPLE GROVE
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State | MN
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Zip | 55369-5530
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Country | US
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Telephone | 612-598-8555
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Fax |
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | HENRY MOMANYI
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Credential | NP
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Telephone | 612-598-8555
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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