Healthcare Provider Details

I. General information

NPI: 1760106264
Provider Name (Legal Business Name): MARIAH LYN HLAVA APRN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARIAH LYN SANDSTROM

II. Dates (important events)

Enumeration Date: 09/28/2022
Last Update Date: 12/21/2022
Certification Date: 12/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E 3RD ST
DULUTH MN
55805-1951
US

IV. Provider business mailing address

400 E 3RD ST
DULUTH MN
55805-1951
US

V. Phone/Fax

Practice location:
  • Phone: 218-786-8364
  • Fax:
Mailing address:
  • Phone: 218-786-8364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9593
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13288
License Number StateWI
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number9593
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: