Provider Demographics
NPI:1265916951
Name:HANSON, AMBER LEA (LN)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:LEA
Last Name:HANSON
Suffix:
Gender:F
Credentials:LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3518 JOHNSON ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-1413
Mailing Address - Country:US
Mailing Address - Phone:612-245-1343
Mailing Address - Fax:
Practice Address - Street 1:2025 4TH ST
Practice Address - Street 2:
Practice Address - City:WHITE BEAR LAKE
Practice Address - State:MN
Practice Address - Zip Code:55110-2762
Practice Address - Country:US
Practice Address - Phone:612-787-2281
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-19
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNN228133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist