Healthcare Provider Details

I. General information

NPI: 1386006732
Provider Name (Legal Business Name): LUCY WHITNEY STANDISH M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 03/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18525 MAPLE RIDGE RD
WAYZATA MN
55391-2629
US

IV. Provider business mailing address

18525 MAPLE RIDGE RD
WAYZATA MN
55391-2629
US

V. Phone/Fax

Practice location:
  • Phone: 612-750-8085
  • Fax:
Mailing address:
  • Phone: 612-750-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number40618
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: