Basic Information
Provider Information | |||||||||
NPI: | 1407866510 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ST MARTIN | ||||||||
FirstName: | SAUNDA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP, APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 155 | ||||||||
Address2: |   | ||||||||
City: | BEMIDJI | ||||||||
State: | MN | ||||||||
PostalCode: | 566190155 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2182091137 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 24760 HOSPITAL DRIVE | ||||||||
Address2: |   | ||||||||
City: | REDLAKE | ||||||||
State: | MN | ||||||||
PostalCode: | 56671 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2186793912 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2006 | ||||||||
LastUpdateDate: | 08/17/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 364S00000X | R1077485 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist |   | 364SP0808X | R107748-5 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Clinical Nurse Specialist | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | 014080500 | 05 | MN |   | MEDICAID | 107121 | 01 | MN | HEALTH PARTNERS | OTHER | 13481 | 05 | ND |   | MEDICAID | 78M12ST | 01 | MN | BCBS | OTHER | P00184098 | 01 | MN | RR MEDICARE | OTHER | 0199999 | 01 | MN | MEDICA | OTHER |