Provider Demographics
NPI:1942704895
Name:HERTZOG, ERICA L (PHN)
Entity Type:Individual
Prefix:
First Name:ERICA
Middle Name:L
Last Name:HERTZOG
Suffix:
Gender:F
Credentials:PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1120 WAYZATA BLVD E STE 210
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-1915
Mailing Address - Country:US
Mailing Address - Phone:952-443-4600
Mailing Address - Fax:952-443-4604
Practice Address - Street 1:1120 WAYZATA BLVD E STE 210
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-1915
Practice Address - Country:US
Practice Address - Phone:320-864-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR-186114-1163WC1500X
MN9957363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health