Healthcare Provider Details

I. General information

NPI: 1538001920
Provider Name (Legal Business Name): ANNA PETERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4130 RAHN RD APT 115
EAGAN MN
55122-2185
US

IV. Provider business mailing address

1960 CLIFF LAKE RD STE 129
EAGAN MN
55122-2439
US

V. Phone/Fax

Practice location:
  • Phone: 651-243-0723
  • Fax:
Mailing address:
  • Phone: 651-243-0723
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number25006014
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: