=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821417619
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LANESSA HERSCH RN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/09/2014
-----------------------------------------------------
Last Update Date | 05/30/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 825 28TH ST S SUITE A
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58103-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-793-4369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 825 28TH ST S SUITE A
-----------------------------------------------------
City | FARGO
-----------------------------------------------------
State | ND
-----------------------------------------------------
Zip | 58103-2325
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 701-793-4369
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | R31877
-----------------------------------------------------
License Number State | ND
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 163WH0200X
-----------------------------------------------------
Taxonomy Name | Home Health Registered Nurse
-----------------------------------------------------
License Number | R168292-2
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------