Healthcare Provider Details

I. General information

NPI: 1598461352
Provider Name (Legal Business Name): ANNEKA MARIE BOOMSMA DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANNEKA 1598461352

II. Dates (important events)

Enumeration Date: 02/03/2023
Last Update Date: 04/24/2026
Certification Date: 04/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9645 GROVE CIR N STE 100
MAPLE GROVE MN
55369-2682
US

IV. Provider business mailing address

4225 GOLDEN VALLEY RD
GOLDEN VALLEY MN
55422-4215
US

V. Phone/Fax

Practice location:
  • Phone: 763-302-4114
  • Fax: 763-287-2303
Mailing address:
  • Phone: 763-588-0661
  • Fax: 763-282-2303

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number13797
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: