MEDICARE: HEATHER COLLEEN LUNDBERG ACNS-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	364SA2200X	Adult Health Clinical Nurse Specialist	R 158404-6	MN

General Provider Information

NPI Number	:	1376850396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER COLLEEN LUNDBERG ACNS-BC

Provider Business Mailing Address
First Line	:	2086 BLOMQUIST AVE
Second Line	:
City	:	WHITE BEAR LAKE
State	:	MN
Zip	:	55110-4702
Country	:	US
Telephone Number	:	651-429-6900
Fax Number	:

Provider Business Practice Location Address
First Line	:	6363 FRANCE AVE S
Second Line	:	SUITE 610
City	:	EDINA
State	:	MN
Zip	:	55435-2129
Country	:	US
Telephone Number	:	952-836-3741
Fax Number	:	952-836-3646

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/13/2010
Last Update Date	:	09/13/2010

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