Provider Demographics
NPI:1770638710
Name:LOFTUS, MARYANN RUTH (CDE)
Entity Type:Individual
Prefix:
First Name:MARYANN
Middle Name:RUTH
Last Name:LOFTUS
Suffix:
Gender:F
Credentials:CDE
Other - Prefix:
Other - First Name:MARYANN
Other - Middle Name:RUTH
Other - Last Name:EDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CDE
Mailing Address - Street 1:4215 EAU CLAIRE TRL NE
Mailing Address - Street 2:
Mailing Address - City:PRIOR LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:55372-1731
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 W 98TH ST
Practice Address - Street 2:SUITE 20
Practice Address - City:BLOOMINGTON
Practice Address - State:MN
Practice Address - Zip Code:55420-4773
Practice Address - Country:US
Practice Address - Phone:952-885-6150
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2010-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR0603012163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator