Provider Demographics
NPI:1508306044
Name:REESE, THERESA RAE (APRN, PNP-PC)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:RAE
Last Name:REESE
Suffix:
Gender:F
Credentials:APRN, PNP-PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3381 SPRING GLEN CIR NW
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1752
Mailing Address - Country:US
Mailing Address - Phone:651-434-9753
Mailing Address - Fax:
Practice Address - Street 1:202 N CEDAR AVE STE 1
Practice Address - Street 2:
Practice Address - City:OWATONNA
Practice Address - State:MN
Practice Address - Zip Code:55060-2306
Practice Address - Country:US
Practice Address - Phone:651-434-9753
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-02
Last Update Date:2023-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR2052469-8363LP0200X
MN5044363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics