=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902293855
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOANNAH BLUNTACH PMHNP-BC
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/17/2015
-----------------------------------------------------
Last Update Date | 06/06/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4135 RICHARD AVE STE 201
-----------------------------------------------------
City | HERMANTOWN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55811-2979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-429-1011
-----------------------------------------------------
Fax | 855-631-0016
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4135 RICHARD AVE STE 201
-----------------------------------------------------
City | HERMANTOWN
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55811-2979
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 612-429-1011
-----------------------------------------------------
Fax | 855-631-0016
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | 4701
-----------------------------------------------------
License Number State | HI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | CNP 3842
-----------------------------------------------------
License Number State | MN
-----------------------------------------------------