Healthcare Provider Details

I. General information

NPI: 1447410931
Provider Name (Legal Business Name): VICKI LYNN NIEDZWIESKI MS, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2008
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 W 66TH ST SUITE 290
EDINA MN
55435-2111
US

IV. Provider business mailing address

11067 OREGON CIR
BLOOMINGTON MN
55438-2457
US

V. Phone/Fax

Practice location:
  • Phone: 952-914-1741
  • Fax:
Mailing address:
  • Phone: 651-274-0381
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberR129718-4
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: