Healthcare Provider Details

I. General information

NPI: 1508754979
Provider Name (Legal Business Name): ALEXANDRA LYNN LIETHEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9645 GROVE CIR N STE 100
MAPLE GROVE MN
55369-2682
US

IV. Provider business mailing address

11050 CEDAR HILLS BLVD APT 323
MINNETONKA MN
55305-3057
US

V. Phone/Fax

Practice location:
  • Phone: 763-302-4114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: