Healthcare Provider Details

I. General information

NPI: 1659994648
Provider Name (Legal Business Name): ANDREE WILSON-NIXA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2020
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14135 CEDAR AVE STE 100
APPLE VALLEY MN
55124-4523
US

IV. Provider business mailing address

9214 COLUMBUS AVE S
BLOOMINGTON MN
55420-3848
US

V. Phone/Fax

Practice location:
  • Phone: 952-432-4373
  • Fax:
Mailing address:
  • Phone: 574-855-0687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number13369
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: