Provider Demographics
NPI:1174328140
Name:GESEMBE, SALLY M
Entity type:Individual
Prefix:DR
First Name:SALLY
Middle Name:M
Last Name:GESEMBE
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 1:13571 HYNES RD
Mailing Address - Street 2:
Mailing Address - City:ROGERS
Mailing Address - State:MN
Mailing Address - Zip Code:55374-9502
Mailing Address - Country:US
Mailing Address - Phone:612-242-9833
Mailing Address - Fax:
Practice Address - Street 1:13571 HYNES RD
Practice Address - Street 2:
Practice Address - City:ROGERS
Practice Address - State:MN
Practice Address - Zip Code:55374-9502
Practice Address - Country:US
Practice Address - Phone:612-242-9833
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-14
Last Update Date:2025-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN12516363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily