Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist |
NPI | 1043538531 |
---|---|
Provider Name | Jill Prinsen |
First Address | Saint Paul, MN 55102-2564 |
Second Address | Saint Paul, MN 55102-2564 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/05/2010 |
Last Update Date | 10/05/2010 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CP003671 | ABC CERTIFICATION NUMBER (01) |