=====================================================
General NPI Number Information
=====================================================
NPI Number | 1770113748
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHRISTINE FOSSUM CNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/18/2020
-----------------------------------------------------
Last Update Date | 03/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2277 HIGHWAY 36 W STE 140
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-3895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-934-7161
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2277 HIGHWAY 36 W STE 140
-----------------------------------------------------
City | ROSEVILLE
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55113-3895
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
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 | 6366
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------