Basic Information
Provider Information | |||||||||
NPI: | 1457753295 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ZIMMERMAN-DESCHEPPER | ||||||||
FirstName: | TRACY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28 NW 4TH STREET | ||||||||
Address2: | SUITE A | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 557442714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2189997750 | ||||||||
FaxNumber: | 2189999461 | ||||||||
Practice Location | |||||||||
Address1: | 28 NW 4TH STREET | ||||||||
Address2: | SUITE A | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MN | ||||||||
PostalCode: | 557442714 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2183261274 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/24/2014 | ||||||||
LastUpdateDate: | 05/15/2017 | ||||||||
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 | 363LP0808X | 2014011459 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | CNP3914 | MN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
ID | Type | State | Issuer | Description | CO8154 | 01 | MN | MEDICARE PTAN | OTHER | 72560NO | 01 | MN | BCBS | OTHER | 894755400 | 05 | MN |   | MEDICAID |