Provider Demographics
NPI:1376850396
Name:LUNDBERG, HEATHER COLLEEN (ACNS-BC)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:COLLEEN
Last Name:LUNDBERG
Suffix:
Gender:F
Credentials:ACNS-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2086 BLOMQUIST AVE
Mailing Address - Street 2:
Mailing Address - City:WHITE BEAR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55110-4702
Mailing Address - Country:US
Mailing Address - Phone:651-429-6900
Mailing Address - Fax:
Practice Address - Street 1:6363 FRANCE AVE S
Practice Address - Street 2:SUITE 610
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2129
Practice Address - Country:US
Practice Address - Phone:952-836-3741
Practice Address - Fax:952-836-3646
Is Sole Proprietor?:No
Enumeration Date:2010-09-13
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 158404-6364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health