Healthcare Provider Details

I. General information

NPI: 1710815725
Provider Name (Legal Business Name): RYAN NELSON
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2026
Last Update Date: 05/11/2026
Certification Date: 05/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2540 COUNTY ROAD F E
WHITE BEAR LAKE MN
55110-3935
US

IV. Provider business mailing address

2540 COUNTY ROAD F E
WHITE BEAR LAKE MN
55110-3935
US

V. Phone/Fax

Practice location:
  • Phone: 651-415-5500
  • Fax:
Mailing address:
  • Phone: 651-415-5500
  • Fax: 651-415-5510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number105858
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: