Basic Information
Provider Information | |||||||||
NPI: | 1174990089 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GUNN | ||||||||
FirstName: | JENNILYN | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | CNP, RN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 3300 OAKDALE AVE. NO. | ||||||||
Address2: |   | ||||||||
City: | ROBBINSDALE | ||||||||
State: | MN | ||||||||
PostalCode: | 55422 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 3300 OAKDALE AVE N | ||||||||
Address2: |   | ||||||||
City: | ROBBINSDALE | ||||||||
State: | MN | ||||||||
PostalCode: | 554222926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7635205200 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/26/2015 | ||||||||
LastUpdateDate: | 10/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | 5222 | MN | Y |   | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |   | 163WC0200X | R214630-2 | MN | N |   | Nursing Service Providers | Registered Nurse | Critical Care Medicine | 2086S0102X | 5222 | MN | N |   | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care | 2086S0127X | 5222 | MN | N |   | Allopathic & Osteopathic Physicians | Surgery | Trauma Surgery | 363LA2100X | 5222 | MN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care | 390200000X | RN.421986 | OH | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.