Provider Demographics
NPI:1447857669
Name:BURSCH-TEWALT, KIMBERLY DAWN (NP-C)
Entity type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:DAWN
Last Name:BURSCH-TEWALT
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MS
Other - First Name:KIMBERLY
Other - Middle Name:DAWN
Other - Last Name:BURSCH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:11884 237TH AVE NW
Mailing Address - Street 2:
Mailing Address - City:ELK RIVER
Mailing Address - State:MN
Mailing Address - Zip Code:55330-8255
Mailing Address - Country:US
Mailing Address - Phone:763-516-6777
Mailing Address - Fax:
Practice Address - Street 1:11884 237TH AVE NW
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-8255
Practice Address - Country:US
Practice Address - Phone:763-516-6777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-01
Last Update Date:2020-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN7549363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily