Provider Demographics
NPI:1265810600
Name:KNUTSON, STACY ANN (DC)
Entity type:Individual
Prefix:DR
First Name:STACY
Middle Name:ANN
Last Name:KNUTSON
Suffix:
Gender:F
Credentials:DC
Other - Prefix:MRS
Other - First Name:STACY
Other - Middle Name:ANN
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8563 182ND AVE SE
Mailing Address - Street 2:
Mailing Address - City:BECKER
Mailing Address - State:MN
Mailing Address - Zip Code:55308-8737
Mailing Address - Country:US
Mailing Address - Phone:218-280-6933
Mailing Address - Fax:
Practice Address - Street 1:12631 FREMONT AVE STE 5
Practice Address - Street 2:
Practice Address - City:ZIMMERMAN
Practice Address - State:MN
Practice Address - Zip Code:55398-7100
Practice Address - Country:US
Practice Address - Phone:218-280-6933
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-18
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6082111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor