Provider Demographics
NPI:1447372024
Name:LUNDBORG, NANCY ANN
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:ANN
Last Name:LUNDBORG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:615 1ST AVE NE
Mailing Address - Street 2:SUITE 310
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55413-2447
Mailing Address - Country:US
Mailing Address - Phone:612-436-0295
Mailing Address - Fax:612-436-0163
Practice Address - Street 1:615 1ST AVE NE
Practice Address - Street 2:SUITE 310
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55413-2447
Practice Address - Country:US
Practice Address - Phone:612-436-0295
Practice Address - Fax:612-436-0163
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 049746-4163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62-20249OtherUBH