Provider Demographics
NPI:1174353825
Name:DUNN, DENETTE MAMIE PHILLIPS
Entity type:Individual
Prefix:MS
First Name:DENETTE
Middle Name:MAMIE PHILLIPS
Last Name:DUNN
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:PO BOX 20411
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:MN
Mailing Address - Zip Code:55420-0411
Mailing Address - Country:US
Mailing Address - Phone:612-702-2222
Mailing Address - Fax:
Practice Address - Street 1:10527 165TH ST W
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-5725
Practice Address - Country:US
Practice Address - Phone:952-955-4110
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-07
Last Update Date:2024-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2477500163W00000X
MN2024012143363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse