1205020005 NPI number — MELISSA M. J. BAUMGART APRN-BC

Table of content: DEBRA AGUEDA RN (NPI 1033728688)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205020005 NPI number — MELISSA M. J. BAUMGART APRN-BC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BAUMGART
Provider First Name:
MELISSA
Provider Middle Name:
M. J.
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
APRN-BC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1205020005
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/15/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2196 WHITE BEAR AVE N
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MAPLEWOOD
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55109-2708
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
516-704-0322
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
700 RAYMOND AVE STE 130
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT PAUL
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55114-1778
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
612-895-1510
Provider Business Practice Location Address Fax Number:
833-979-0945
Provider Enumeration Date:
09/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R122944-0 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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