MEDICARE: LINDA RAE VANROEKEL KUISMI RNC/FNP

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	363LF0000X	Family Nurse Practitioner	NP098824-5	MN
2	363LF0000X	Family Nurse Practitioner	2515	MN

General Provider Information

NPI Number	:	1619932100
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LINDA RAE VANROEKEL KUISMI RNC/FNP

Provider Business Mailing Address
First Line	:	56139 110TH ST
Second Line	:
City	:	MENAHGA
State	:	MN
Zip	:	56464-2109
Country	:	US
Telephone Number	:	218-844-5832
Fax Number	:	218-844-5834

Provider Business Practice Location Address
First Line	:	1125 W RIVER RD
Second Line	:
City	:	DETROIT LAKES
State	:	MN
Zip	:	56501-2722
Country	:	US
Telephone Number	:	218-844-5832
Fax Number	:	218-844-5834

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

Provider Enumeration Date	:	04/19/2006
Last Update Date	:	06/10/2019

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