Provider Demographics
NPI:1538410287
Name:NDIFOR, REGINE W (RN, BSN, MSN, FNP)
Entity type:Individual
Prefix:MS
First Name:REGINE
Middle Name:W
Last Name:NDIFOR
Suffix:
Gender:F
Credentials:RN, BSN, MSN, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1415 LILAC DR N STE 190
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55422-4544
Mailing Address - Country:US
Mailing Address - Phone:763-267-8701
Mailing Address - Fax:763-231-9602
Practice Address - Street 1:1415 LILAC DR N STE 190
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55422-4544
Practice Address - Country:US
Practice Address - Phone:763-267-8701
Practice Address - Fax:763-231-9602
Is Sole Proprietor?:No
Enumeration Date:2012-09-20
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN209405-6363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNF68290Medicare UPIN