Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LG0600X | Nurse Practitioner - Gerontology | 18532 | SC |
NPI | 1073943148 |
---|---|
Provider Name | Alicia Gripper |
First Address | Minnetonka, MN 55343-9664 |
Second Address | Minnetonka, MN 55343-9664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/11/2013 |
Last Update Date | 23/06/2020 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NP2610 | (05) | SC |