Provider Demographics
NPI:1194716811
Name:SKURDAHL, MARILYN M (CNP)
Entity type:Individual
Prefix:
First Name:MARILYN
Middle Name:M
Last Name:SKURDAHL
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 CENTRACARE CIR
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-5000
Mailing Address - Country:US
Mailing Address - Phone:320-654-3630
Mailing Address - Fax:320-654-3657
Practice Address - Street 1:1900 CENTRACARE CIR
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-5000
Practice Address - Country:US
Practice Address - Phone:320-654-3630
Practice Address - Fax:320-654-3657
Is Sole Proprietor?:No
Enumeration Date:2005-11-02
Last Update Date:2011-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0957881363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
0104090OtherMEDICA HEALTH PLANS
972587300OtherMEDICAL ASSISTANCE
1020209OtherPREFERRED ONE
73D95SKOtherBLUE CROSS BLUE SHIELD
123625OtherU CARE
HP27108OtherHEALTH PARTNERS
2130074OtherFIRST HEALTH PLAN
1020209OtherPREFERRED ONE
972587300OtherMEDICAL ASSISTANCE