Healthcare Provider Details

I. General information

NPI: 1679404024
Provider Name (Legal Business Name): RITA ANDIK ANANG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/26/2026
Last Update Date: 05/26/2026
Certification Date: 05/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12103 78TH ST NE
OTSEGO MN
55330-4823
US

IV. Provider business mailing address

12103 78TH ST NE
OTSEGO MN
55330-4823
US

V. Phone/Fax

Practice location:
  • Phone: 612-607-9421
  • Fax:
Mailing address:
  • Phone: 612-607-9421
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number14252
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: