Healthcare Provider Details

I. General information

NPI: 1598330219
Provider Name (Legal Business Name): MINNESOTA VITALITY AND ANTI-AGING CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2021
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 HIGHWAY 96 W STE 200
SHOREVIEW MN
55126-1963
US

IV. Provider business mailing address

520 HIGHWAY 96 W STE 200
SHOREVIEW MN
55126-1963
US

V. Phone/Fax

Practice location:
  • Phone: 651-374-4014
  • Fax: 651-374-4019
Mailing address:
  • Phone: 651-374-4014
  • Fax: 651-374-4019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: HEATHER MANSHIP
Title or Position: CO-FOUNDER
Credential:
Phone: 651-245-2454