Provider Demographics
NPI:1780065862
Name:WICKERSHEIM, DANA (NP)
Entity type:Individual
Prefix:
First Name:DANA
Middle Name:
Last Name:WICKERSHEIM
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:683 BIELENBERG DR STE 103
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-1711
Mailing Address - Country:US
Mailing Address - Phone:952-841-2346
Mailing Address - Fax:
Practice Address - Street 1:683 BIELENBERG DR STE 103
Practice Address - Street 2:
Practice Address - City:WOODBURY
Practice Address - State:MN
Practice Address - Zip Code:55125-1711
Practice Address - Country:US
Practice Address - Phone:952-841-2346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-15
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR2095660163W00000X
MN12112363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No163W00000XNursing Service ProvidersRegistered Nurse