=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790497865
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLUEBIRDS & DAFFODILS, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2022
-----------------------------------------------------
Last Update Date | 12/20/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 225 CHIPPEWA ST
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-884-4856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 225 CHIPPEWA ST
-----------------------------------------------------
City | BRAINERD
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 56401-3308
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 507-884-4856
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | KIMBERLY ELAINE HENDERSON
-----------------------------------------------------
Credential | APRN, PMHNP-BC
-----------------------------------------------------
Telephone | 507-884-4856
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------