Provider Demographics
NPI:1336773522
Name:PHILSTROM, HIEDI
Entity type:Individual
Prefix:
First Name:HIEDI
Middle Name:
Last Name:PHILSTROM
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 312
Mailing Address - Street 2:
Mailing Address - City:PINE CITY
Mailing Address - State:MN
Mailing Address - Zip Code:55063-0312
Mailing Address - Country:US
Mailing Address - Phone:612-961-3687
Mailing Address - Fax:
Practice Address - Street 1:56656 STEPHANIE LN
Practice Address - Street 2:
Practice Address - City:PINE CITY
Practice Address - State:MN
Practice Address - Zip Code:55063-9095
Practice Address - Country:US
Practice Address - Phone:612-961-3687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-26
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant