Provider Demographics
NPI:1841695541
Name:KNUDSON, MARYANN BETTY
Entity type:Individual
Prefix:MS
First Name:MARYANN
Middle Name:BETTY
Last Name:KNUDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 3 PLACE N.W.
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901
Mailing Address - Country:US
Mailing Address - Phone:507-206-9207
Mailing Address - Fax:
Practice Address - Street 1:3612 3RD PL NW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55901-7556
Practice Address - Country:US
Practice Address - Phone:507-206-9207
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1066593-2-AFC171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor