=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700075678
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JUSTINE MARIE WAMBACH FNP-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2007
-----------------------------------------------------
Last Update Date | 04/13/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1111 1ST ST
-----------------------------------------------------
City | WAUBUN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56589-4047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-204-0180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29664 COUNTY ROAD 112
-----------------------------------------------------
City | WAUBUN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56589-2800
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 218-204-0180
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 3295
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163W00000X
-----------------------------------------------------
Taxonomy Name | Registered Nurse
-----------------------------------------------------
License Number | R1819494
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------