Basic Information
Provider Information | |||||||||
NPI: | 1235137522 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WREDE | ||||||||
FirstName: | JANE | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | C.N.M. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DRIESEN | ||||||||
OtherFirstName: | JANE | ||||||||
OtherMiddleName: | M. | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 908 N 11TH ST | ||||||||
Address2: |   | ||||||||
City: | MONTEVIDEO | ||||||||
State: | MN | ||||||||
PostalCode: | 562651631 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202696435 | ||||||||
FaxNumber: | 3202694494 | ||||||||
Practice Location | |||||||||
Address1: | 824 N 11TH ST | ||||||||
Address2: |   | ||||||||
City: | MONTEVIDEO | ||||||||
State: | MN | ||||||||
PostalCode: | 562651629 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3202698877 | ||||||||
FaxNumber: | 3203218200 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2005 | ||||||||
LastUpdateDate: | 12/29/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/29/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367A00000X | R136017-6 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |   |
ID Information
ID | Type | State | Issuer | Description | 509181100 | 05 | MN |   | MEDICAID |