MEDICARE: MRS. KELLI MARIE JERDET ENGEN RN, BSN

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	163W00000X	Registered Nurse	160751-030	WI

General Provider Information

NPI Number	:	1730411497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. KELLI MARIE JERDET ENGEN RN, BSN

Provider Business Mailing Address
First Line	:	N6520 GUY ROAD
Second Line	:
City	:	BLACK RIVER FALLS
State	:	WI
Zip	:	54615-1741
Country	:	US
Telephone Number	:	715-284-9851
Fax Number	:	715-284-5150

Provider Business Practice Location Address
First Line	:	N6520 GUY ROAD
Second Line	:	HO-CHUNK HEALTH CARE CENTER
City	:	BLACK RIVER FALLS
State	:	WI
Zip	:	54615-1741
Country	:	US
Telephone Number	:	715-284-9851
Fax Number	:	715-284-5150

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

Provider Enumeration Date	:	02/05/2010
Last Update Date	:	02/05/2010

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