Healthcare Provider Details

I. General information

NPI: 1891881512
Provider Name (Legal Business Name): WENDY SEYLLER OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 01/30/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13481 60TH ST N SUITE 200 ST CROIX VISION CENTER
STILLWATER MN
55082
US

IV. Provider business mailing address

1037 GRIFFIN AVE
MAHTOMEDI MN
55115-1509
US

V. Phone/Fax

Practice location:
  • Phone: 651-439-6400
  • Fax: 651-439-6405
Mailing address:
  • Phone: 651-493-2677
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2105
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: