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General NPI Number Information
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NPI Number | 1902102916
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Entity Type | Individual
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Provider Name | JENNA SUE FICKBOHM L.P.N
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Gender | Female
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Dates
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Enumeration Date | 02/09/2011
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Last Update Date | 02/09/2011
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Provider Practice Location Address
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Address Line | 13483 COUNTY ROAD F
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City | GRANTSBURG
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State | WI
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Zip | 54840-7363
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Country | US
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Telephone | 651-353-5535
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Fax |
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Provider Business Mailing Address
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Address Line | 13483 COUNTY ROAD F
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City | GRANTSBURG
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State | WI
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Zip | 54840-7363
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Country | US
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Telephone | 651-353-5535
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 164W00000X
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Taxonomy Name | Licensed Practical Nurse
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License Number | L068049-1
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License Number State | MN
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