Basic Information
| Provider Information | |||||||||
| NPI: | 1063802155 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STAGEBERG | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | N.P. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5044 GREENWOOD AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKFORD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553734580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7632213945 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 303 CATLIN ST | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553131947 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7636825225 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2015 | ||||||||
| LastUpdateDate: | 01/28/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP2300X | R173943-5 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Primary Care |
No ID Information.