Provider Demographics
NPI:1033320650
Name:WOLLAN, ROBERTA BEA
Entity type:Individual
Prefix:
First Name:ROBERTA
Middle Name:BEA
Last Name:WOLLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:ROBERTA
Other - Middle Name:
Other - Last Name:PETTET
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:13186 GARNET AVE
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:MN
Mailing Address - Zip Code:55124-6108
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 MAIN ST W
Practice Address - Street 2:
Practice Address - City:CANNON FALLS
Practice Address - State:MN
Practice Address - Zip Code:55009-1852
Practice Address - Country:US
Practice Address - Phone:507-263-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2025-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1009251225X00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist