Healthcare Provider Details

I. General information

NPI: 1063365609
Provider Name (Legal Business Name): KIMBERLY ANN ANDERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2026
Last Update Date: 02/16/2026
Certification Date: 02/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 KENWOOD AVE
DULUTH MN
55811-4199
US

IV. Provider business mailing address

325 S LAKE AVE STE 604
DULUTH MN
55802-2364
US

V. Phone/Fax

Practice location:
  • Phone: 218-625-4408
  • Fax:
Mailing address:
  • Phone: 605-323-7672
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number2482161
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: