Basic Information
| Provider Information | |||||||||
| NPI: | 1508306044 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | REESE | ||||||||
| FirstName: | THERESA | ||||||||
| MiddleName: | RAE | ||||||||
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| Credential: | APRN, PNP-PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3381 SPRING GLEN CIR NW | ||||||||
| Address2: | |||||||||
| City: | PRIOR LAKE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553721752 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6514349753 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1900 SILVER LAKE RD NW STE 110 | ||||||||
| Address2: | |||||||||
| City: | NEW BRIGHTON | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551121789 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6516289566 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2017 | ||||||||
| LastUpdateDate: | 03/02/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | R2052469-8 | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
No ID Information.