Provider Demographics
NPI:1710717251
Name:PRUSAK, ANNA MARIE
Entity type:Individual
Prefix:
First Name:ANNA
Middle Name:MARIE
Last Name:PRUSAK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ANNA
Other - Middle Name:MARIE
Other - Last Name:ALTERGOTT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:1401 EAST 1ST STREET
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-2407
Mailing Address - Country:US
Mailing Address - Phone:218-728-4491
Mailing Address - Fax:218-302-8698
Practice Address - Street 1:810 E 4TH ST
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55805-2147
Practice Address - Country:US
Practice Address - Phone:218-728-4491
Practice Address - Fax:218-302-8698
Is Sole Proprietor?:No
Enumeration Date:2024-08-07
Last Update Date:2024-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN11889363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health