Basic Information
| Provider Information | |||||||||
| NPI: | 1366766610 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | STORLIE | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 JEFFERSON RD | ||||||||
| Address2: | |||||||||
| City: | NORTHFIELD | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550573081 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076639000 | ||||||||
| FaxNumber: | 6513451182 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 W GRANT ST | ||||||||
| Address2: | |||||||||
| City: | LAKE CITY | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550411143 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6513453321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/16/2010 | ||||||||
| LastUpdateDate: | 03/03/2016 | ||||||||
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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 | 207Q00000X | 53838 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3134-850 | 01 | WI | TEP | OTHER |