Healthcare Provider Details

I. General information

NPI: 1164279584
Provider Name (Legal Business Name): EMMACULATE BIH AWASOM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2024
Last Update Date: 03/01/2026
Certification Date: 03/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14400 MARTIN DR
EDEN PRAIRIE MN
55344-2031
US

IV. Provider business mailing address

14400 MARTIN DR
EDEN PRAIRIE MN
55344-2031
US

V. Phone/Fax

Practice location:
  • Phone: 952-254-4200
  • Fax:
Mailing address:
  • Phone: 952-254-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number11565
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: