Provider Demographics
NPI:1902146046
Name:THARALDSON, ANGELLA MARIE
Entity Type:Individual
Prefix:DR
First Name:ANGELLA
Middle Name:MARIE
Last Name:THARALDSON
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:ANGELLA
Other - Middle Name:MARIE
Other - Last Name:HEGDAHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5551 SHOREVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55417-1919
Mailing Address - Country:US
Mailing Address - Phone:218-626-7223
Mailing Address - Fax:
Practice Address - Street 1:10 W LAKE ST
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-3116
Practice Address - Country:US
Practice Address - Phone:612-827-5309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-27
Last Update Date:2013-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN120089183500000X
WI16158-040183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist