Healthcare Provider Details

I. General information

NPI: 1376516831
Provider Name (Legal Business Name): LEE ANN HERTZOG DONOVAN CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: LEE ANN HERTZOG

II. Dates (important events)

Enumeration Date: 02/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

250 N CENTRAL AVE #101
WAYZATA MN
55391
US

IV. Provider business mailing address

250 N CENTRAL AVE #101
WAYZATA MN
55391
US

V. Phone/Fax

Practice location:
  • Phone: 952-473-0211
  • Fax: 952-473-7908
Mailing address:
  • Phone: 952-473-0211
  • Fax: 952-473-7908

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberR1497120
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: