Basic Information
| Provider Information | |||||||||
| NPI: | 1740264597 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEMMA | ||||||||
| FirstName: | JENNIFER | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | CNM | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MURRAY | ||||||||
| OtherFirstName: | JENNIFER | ||||||||
| OtherMiddleName: | J | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1619 DAYTON AVE | ||||||||
| Address2: | 205 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551046206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516450478 | ||||||||
| FaxNumber: | 6516422523 | ||||||||
| Practice Location | |||||||||
| Address1: | 1619 DAYTON AVE | ||||||||
| Address2: | 205 | ||||||||
| City: | SAINT PAUL | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551046206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516450478 | ||||||||
| FaxNumber: | 6516422523 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2005 | ||||||||
| LastUpdateDate: | 09/17/2015 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | R1512403 | MN | N | Nursing Service Providers | Registered Nurse | 367A00000X | CNM0050 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
ID Information
| ID | Type | State | Issuer | Description | MD3431765 | 01 | DEA NUMBER | OTHER |