Healthcare Provider Details

I. General information

NPI: 1386195659
Provider Name (Legal Business Name): CHELSEA VICTORIA DOMEIER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2016
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 LAKE ST S
FOREST LAKE MN
55025-2628
US

IV. Provider business mailing address

2925 CHICAGO AVE
MINNEAPOLIS MN
55407-1321
US

V. Phone/Fax

Practice location:
  • Phone: 651-464-7100
  • Fax: 651-241-1515
Mailing address:
  • Phone: 612-262-9000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2610
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: