Provider Demographics
NPI:1376516831
Name:HERTZOG DONOVAN, LEE ANN (CPNP)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:HERTZOG DONOVAN
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:LEE
Other - Middle Name:ANN
Other - Last Name:HERTZOG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:250 N CENTRAL AVE
Mailing Address - Street 2:#101
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391
Mailing Address - Country:US
Mailing Address - Phone:952-473-0211
Mailing Address - Fax:952-473-7908
Practice Address - Street 1:250 N CENTRAL AVE
Practice Address - Street 2:#101
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391
Practice Address - Country:US
Practice Address - Phone:952-473-0211
Practice Address - Fax:952-473-7908
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR1497120163WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0200XNursing Service ProvidersRegistered NursePediatrics