Healthcare Provider Details

I. General information

NPI: 1104569243
Provider Name (Legal Business Name): SAVANNAH NELLES MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2022
Last Update Date: 08/29/2025
Certification Date: 08/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5320 HYLAND GREENS DR
BLOOMINGTON MN
55437-3934
US

IV. Provider business mailing address

8170 33RD AVE S # MS 21110Q
BLOOMINGTON MN
55425-4516
US

V. Phone/Fax

Practice location:
  • Phone: 952-993-2400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number75284
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: