MEDICARE: RELINDIS ANGIRISA MOFFOR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WA2000X	Administrator Registered Nurse	164080-9	MN

General Provider Information

NPI Number	:	1639957616
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RELINDIS ANGIRISA MOFFOR

Provider Business Mailing Address
First Line	:	1597 HILO AVE N
Second Line	:
City	:	OAKDALE
State	:	MN
Zip	:	55128-5620
Country	:	US
Telephone Number	:	651-283-3546
Fax Number	:

Provider Business Practice Location Address
First Line	:	330 EXCHANGE ST S
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55102-2311
Country	:	US
Telephone Number	:	651-227-0336
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/20/2023
Last Update Date	:	09/20/2023

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