Healthcare Provider Details

I. General information

NPI: 1316900590
Provider Name (Legal Business Name): SALLY H ENGEBRETSON DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: SALLY JEANNIE HOLMES DO

II. Dates (important events)

Enumeration Date: 04/10/2006
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1421 WAYZATA BLVD STE 200
WAYZATA MN
55391-2071
US

IV. Provider business mailing address

1421 WAYZATA BLVD STE 200
WAYZATA MN
55391-2071
US

V. Phone/Fax

Practice location:
  • Phone: 952-592-4235
  • Fax: 952-600-8461
Mailing address:
  • Phone: 952-592-4235
  • Fax: 952-600-8461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number43959
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: